Respiratory Viruses Having Pandemic Potential · The plan focuses on the roles and responsibilities...

RESPIRATORY VIRUSES HAVING PANDEMIC POTENTIAL

Public Health Preparedness, Surveillance, and Response Plan for Texas

DEPARTMENT OF STATE HEALTH SERVICES

Version 1.2 March 2015

This document is intended to provide guidance and is not prescriptive or comprehensive. Use judgment and discretion to determine the most appropriate actions at the time of an incident. These guidelines do not override local or regional plans, but are designed to complement those planning activities. This document does not prohibit any jurisdiction from implementing additional requirements or operating procedures within that jurisdiction.

For more information regarding this document, please contact: TEXAS DEPARTMENT OF STATE HEALTH SERVICES

DIVISION OF REGIONAL & LOCAL HEALTH SERVICES: COMMUNITY PREPAREDNESS SECTION RESPONSE & RECOVERY UNIT PLANNING TEAM

[email protected]

Table of Contents

I. Preface ................................................................................................................................ 1 II. Executive Summary............................................................................................................. 2 III. Background ......................................................................................................................... 3 IV. Roles and Responsibilities................................................................................................... 4 V. Operational Levels and Response Activities ........................................................................ 9

A. Local Jurisdictions, Including Health Service Region Offices Conducting Local Health Department Functions ............................................................................................................. 9 B. Central Office and Health Service Regions ...................................................................... 9

VI. Acronyms .......................................................................................................................... 52 VII. References ........................................................................................................................ 53 VIII. Record of Changes ........................................................................................................... 54 IX. Contributors ....................................................................................................................... 55 X. Supplements ..................................................................................................................... 56

DSHS Programmatic Response Activities ............................................................................. 56

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Texas Department of State Health Services Respiratory Viruses Having Pandemic Potential: Public Health Preparedness, Surveillance, and Response Plan for Texas

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I. PREFACE An influenza pandemic is the most likely public health threat to occur that has the potential for high morbidity and mortality, as well as significant disruptions to normal activities over a broad area. Influenza viruses, as well as certain other respiratory viruses, are readily transmitted in a population, mutate frequently so that most of the population has little if any immunity to new strains, and cause severe illness and death. Recently, a novel strain of H7N9 influenza and a novel coronavirus, the Middle Eastern Respiratory Syndrome coronavirus, have emerged; both viruses have been associated with high fatality rates. This Public Health Preparedness, Surveillance, and Response Plan for Respiratory Viruses Having Pandemic Potential describes appropriate virus surveillance activities and responses for different levels of virus and other activity detected. The plan details specific activities for programs and executive leadership within the Texas Department of State Health Services (DSHS), local health departments (LHDs), and state and regional planning partners. OBJECTIVES OF THE PLAN

To describe appropriate activities for surveillance and control of respiratory viruses with

pandemic potential, including influenza; To prompt surveillance and control activities appropriate for estimated virus transmission risk

and severity levels; To prompt activation of a Regional Health and Medical Operations Center (RHMOC), the State

Medical Operations Center (SMOC), and/or a local Emergency Operations Center (EOC); To provide local and state public health agencies with a decision support system; and To define the roles and responsibilities of local and state public health entities tasked with

pandemic influenza and other respiratory virus surveillance and response activities.

SCOPE OF THE PLAN The plan focuses on the roles and responsibilities of different programs and areas within DSHS and local jurisdictions that would play a role during a novel respiratory virus outbreak or pandemic. The plan identifies five phases of an outbreak or pandemic and the existing conditions that define each phase. It separately describes the expected activities for both DSHS and LHDs, including activities for areas where DSHS Health Service Region (HSR) offices conduct LHD functions, for each of the five phases. PUBLIC HEALTH EMERGENCY PREPAREDNESS CAPABILITIES This document addresses the following U.S. Centers for Disease Control and Prevention (CDC) Public Health Emergency Preparedness (PHEP) capabilities: Community Preparedness Emergency Operations Coordination Emergency Public Information and Warning Information Sharing Medical Countermeasures Dispensing Non-Pharmaceutical Interventions Public Health Laboratory Testing Public Health Surveillance and Epidemiological Investigation


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II. EXECUTIVE SUMMARY The purpose of this response plan is to share information within and outside of the Texas DSHS regarding preparation for and response to pandemics caused by respiratory viruses, including influenza and related viruses. ROLES AND RESPONSIBILTIES This plan describes the following DSHS responsibilities in preparation for and during a respiratory virus pandemic: To assist local jurisdictions with surveillance and epidemiologic data collection and

interpretation, laboratory testing, risk communication, medical support, and other resources as appropriate

To act as the state coordinating entity for laboratory testing, surveillance, case definitions, data analysis, and distribution of medical countermeasures

To provide guidance to local jurisdictions regarding community mitigation decisions To act as liaison with other state and federal agencies Further, this plan describes the following activities for LHDs and for DSHS HSR offices conducting LHD functions: To conduct routine, year-round influenza and respiratory virus surveillance activities To investigate human cases of novel influenza and other respiratory viruses in their jurisdiction To coordinate with local emergency management to share information using incident

management communication infrastructures and to facilitate the fulfillment of public health and medical service support needs

OPERATIONAL ACTIVITIES This document provides a plan for DSHS and LHD responses to a respiratory virus outbreak or pandemic that is based on the scale of activity in the state or in a locale within the state. Five phases of response based on increasing severity of an outbreak or pandemic—Routine Operations, Enhanced Operations, Increased Readiness Operations, Escalated Operations, and Emergency Response—are described. The key components ascertained to determine the severity level at a particular time include the following: Burden of human illness Geographic distribution of cases Travel-related status of human cases Presence of sustained human-to-human transmission Complexity of investigations Level of public or media attention Presence of animal cases The operational activities are described first for local jurisdictions. Then, operational activities that apply to both the DSHS HSRs and Central Office are described. For both the local jurisdiction and DSHS operational activities, and for each phase of activity, the conditions occurring are first described. These are followed by appropriate response activities related to laboratories, surveillance and epidemiology, communication, incident management, immunizations, non-pharmaceutical interventions, and medical countermeasures. The scaling of conditions provides local and DSHS officials key information they will need to make appropriate response decisions.


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III. BACKGROUND Influenza is an acute infectious disease caused by one of three types of viruses, influenza A, B, and C. These viruses cause respiratory illness, which can be severe and even fatal, especially when accompanied by pneumonia. Generally, persons at extremes of age or who are immune compromised are at greatest risk for developing severe illness. In the U.S., 5-10 percent of the population gets influenza each year, and more than 200,000 are hospitalized for influenza-related complications. Influenza and pneumonia together rank about 8th every year among causes of mortality in the U.S. Seasonal or “regular” influenza viruses circulate routinely in humans and are readily transmitted within populations, primarily through droplet spread when an infected person coughs or sneezes, but also by indirect contact with contaminated surfaces. All influenza viruses undergo small, continual mutations in their genetic compositions, called “antigenic drift.” These small changes are the reason that one or more of the influenza vaccine strains change each year and also why people should be vaccinated annually against influenza. Large mutations in the genetic material specifying surface proteins can also occur in influenza A viruses, through a process called “antigenic shift.” These large changes in the virus can lead to influenza pandemics. Every year, the World Health Organization (WHO) recommends specific influenza virus strains for inclusion in seasonal influenza vaccines, based on international surveillance data. The U.S. Food and Drug Administration (FDA) bases its decision on which vaccine strains will be manufactured in the U.S. using the WHO recommendations. Vaccine manufacturers immediately begin the months-long process of vaccine production so that adequate quantities will be available before the influenza season begins. Wild aquatic birds are the primary influenza A reservoir, but influenza A viruses also infect domestic poultry and other animals, such as swine. These animals may or may not develop illness when they are infected, depending on the species and the virus type. Different strains occur in various species of mammals and birds. Some influenza A viruses can “jump” from animal hosts to humans. This is most likely to occur when people live and work in close proximity to the animal hosts. A mutation in an influenza virus that normally circulates in avian or swine populations can make human infections with that virus strain possible. Mutations can also cause a viral strain that had previously spread only between animals to spread efficiently between humans as well. New strains of influenza viruses that jump from a non-human animal to humans and that also can be readily transmitted between humans have the potential for causing widespread epidemics and pandemics of influenza, with large numbers of fatalities. The 1918-1919 influenza pandemic is estimated to have caused 30-50 million deaths worldwide. Pandemics occur when immunity to a strain is absent in the majority of the population. The virus most likely to cause a pandemic of respiratory illnesses is influenza A. However, other viruses, such as the Severe Acute Respiratory Syndrome-associated Coronavirus (SARS) and other coronaviruses, such as the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), also have the potential to cause pandemics. Regardless of the respiratory virus responsible for the outbreak or pandemic, the response activities and decision making components described herein would be the same. In addition, the surveillance and epidemiology activities would be similar. This plan is sufficiently flexible to address a small outbreak of a novel virus, a severe influenza season, or a novel influenza pandemic.


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IV. ROLES AND RESPONSIBILITIES LABORATORY SURVEILLANCE Laboratory surveillance for influenza viruses in Texas involves a variety of activities. The activities described below are conducted at DSHS facilities. LHDs, providers, and other entities may also conduct laboratory surveillance. DSHS provides human specimen collection, shipping, and testing at no charge for approved influenza laboratory surveillance participants, including Outpatient Influenza-Like-Illness (ILI)Net providers. DSHS also participates in the Influenza Incidence Surveillance Project (IISP). In Texas, this program has been rebranded as “Enhanced ILINet (Influenza-like Illness Surveillance Network)/IISP” due to slight changes in IISP methods. Clinical specimens are tested at the DSHS Austin laboratory for influenza and other respiratory viruses including adenovirus, respiratory syncytial virus, human metapneumovirus, rhinovirus, and parainfluenza viruses 1-3. The DSHS Austin laboratory may also test for other respiratory viruses, if indicated. Influenza virus surveillance at the state level consists of influenza test results reported by Texas laboratories in the National Respiratory and Enteric Virus Surveillance System (NREVSS) and specimens sent to public health laboratories (e.g., the DSHS Austin laboratory and the Laboratory Response Network [LRN] Laboratories) for influenza surveillance testing. EPIDEMIOLOGIC SURVEILLANCE, INVESTIGATION, AND ANALYSIS Influenza surveillance in Texas occurs year-round, although in reduced capacity during the summer months. DSHS Emerging and Acute Infectious Disease Branch (EAIDB) epidemiologists routinely monitor information sources for potentially significant changes in respiratory virus activity in Texas, nationally, and worldwide. These staff members communicate regularly with state and national respiratory virus surveillance partners. About 100 sentinel healthcare providers in Texas participate in the U.S. Outpatient ILINet. These providers report the number and proportion of outpatient visits for influenza-like illness (ILI) at their facilities weekly throughout the influenza season (October through May) to U.S. Centers for Disease Control and Prevention (CDC). Seasonal influenza cases are generally not reported to either DSHS or LHDs. Laboratory-confirmed cases of novel influenza A are reportable by law in Texas, as are laboratory-confirmed cases with other emerging respiratory virus infections. Respiratory virus outbreaks are also reportable by law. Influenza-related deaths that occur among pediatric patients (children < 18 years of age) are also reportable in Texas. These cases must be laboratory-confirmed. Adult influenza-related deaths are not reportable to DSHS or CDC, though some LHDs require this information to be collected and reported to them. Most LHDs in Texas report influenza surveillance data weekly to the DSHS HSRs; the DSHS HSRs compile these data, along with the data they collect themselves, and submit them weekly to DSHS EAIDB. Sentinel surveillance sites and laboratory surveillance partners report data weekly to LHDs, DSHS EAIDB, or CDC according to established protocols. DSHS EAIDB compiles, analyzes, and organizes the reported influenza and other respiratory virus surveillance data and


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produces the weekly Texas Influenza Surveillance Report. The state influenza report is posted weekly, year-round, on the DSHS website. LHDs and DSHS HSRs may conduct enhanced or additional surveillance activities, particularly when unusual respiratory virus activity is detected. The Texas Animal Health Commission (TAHC) also reports certain animal infections to DSHS Zoonosis Control Branch (ZCB). The TAHC reports occurrences of H5 and H7 influenza in poultry, novel H1N1 influenza in swine, and any other novel influenza virus in livestock or poultry that has been associated with confirmed human illness. COMMUNICATION The Center for Policy and External Affairs (CPEA) at DSHS Central Office is responsible for communication of influenza-related information to the general public, the news media, and the Legislature. CPEA also coordinates with DSHS HSRs and LHDs when appropriate for public risk communication. LHD officials may provide their own messages within their jurisdictions. Risk communications from DSHS to the general public may include press releases, social media messaging, public service announcements, public education campaigns, and other forms of communication that convey information about potential public health threats such as outbreaks, educational materials the public can use to prepare and protect themselves from disease, as well as details about any services DSHS might be offering to the public. CPEA is also responsible for communicating and coordinating with other governmental agencies in the state, providing briefings and other materials for elected officials in Texas, and communicating with officials in other states and federal agencies. Communication within DSHS, between DSHS and LHDs, and with other agencies within Texas is described in the appropriate areas of the operational sections, V.A and B, of this plan. INCIDENT MANAGEMENT When an outbreak occurs, consideration is given to activating emergency response resources to assist in controlling the spread of disease. Depending on the size and circumstances of an outbreak, there might be no activation, partial activation, or full activation of the SMOC. SMOC support is typically requested when an outbreak is large enough that regular resources are strained and information sharing demands are high. The SMOC may also be partially or fully activated during a public health emergency that requires collaboration with partner agencies. Staff in the DSHS Community Preparedness Section (CPS), Response and Recovery Unit, maintain the SMOC during non-disaster times. They also communicate with staff throughout the agency to receive early warnings of potential SMOC activations. These staff members, along with staff in other areas of DSHS Central Office and the Health and Human Services Commission (HHSC) Enterprise, receive training in Incident Command System (ICS) structure and work in the SMOC during a disaster. Staff members from impacted programs may be called to serve as subject matter experts (SMEs) to ensure situational awareness and provide necessary input to SMOC leadership decision making. The SMEs work in the SMOC, or remotely from their duty station. SMOC staff manages outbreak response using ICS. The SMOC coordinates with the Texas Division of Emergency Management (TDEM), as well as other agencies, businesses, and organizations within and outside of the state to fulfill requests for


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response resources. The SMOC coordinates communication with executive leadership at DSHS. The SMOC collects, shares as appropriate, and otherwise manages incoming and outgoing information during the outbreak or pandemic. It collects data on surveillance, epidemiology, vaccine and medical countermeasures, medical system impact, staff time worked, response cost, and other data as appropriate. Daily reports are generated using standard ICS forms and shared as deemed appropriate for the response. Requests from local jurisdictions for public health and medical surge support are also processed by the SMOC. Eight RHMOCs are strategically located around the state to serve as public health and medical coordination centers for the DSHS HSRs. The RHMOCs are activated by HSR leadership to coordinate public health and medical information sharing and response resources at the regional level. Depending on the incident, the RHMOC may be activated either prior to or after the SMOC is activated, or in cases when the SMOC never activated. Like the SMOC, the RHMOC coordinates with multiple response partners, including TDEM, other state agencies, businesses, and organizations. NON-PHARMACEUTICAL INTERVENTIONS Disease Mitigation in Communities Non-pharmaceutical intervention strategies reduce the risk of transmission by decreasing the probability of contact between infected and uninfected people and by decreasing the probability that contact will result in infection. These strategies can be applied at the individual or community level. Individual measures may include voluntary home isolation of ill persons; quarantine of well persons who have been exposed to ill persons; practicing good personal hand and respiratory hygiene including hand washing and cough etiquette, and routine cleaning of frequently touched surfaces and objects; and the use of respiratory protective devices (RPDs) such as masks or respirators, particularly for the healthcare workforce. Community-based measures include community activity restrictions such as restricting mass gatherings; early coordinated closures of childcare facilities, K-12 schools, and colleges and universities before influenza transmission becomes widespread; and workplace social distancing measures that reduce face-to-face contact among employees and between employees and customers. DSHS decisions on community mitigation recommendations during a pandemic are made by executive leadership, infectious disease control staff, and other staff as appropriate. Medical Care and Countermeasures During an outbreak or pandemic of a respiratory virus, healthcare systems will likely experience a surge in patients, shortages of equipment and supplies (including medications), and significant staff absenteeism. DSHS provides medical and other resources aimed at reducing the impact of the disease on the population. LHDs may also provide such resources. Local or regional jurisdictions can choose to activate their pandemic response plans, which may include the use of alternate care sites. Alternate care sites may include community facilities, such as churches and schools, or temporary facilities established in close proximity to a hospital or clinic. When an alternate care site is established, the RHMOC or SMOC supports local response activities by providing supplemental medical equipment, supplies, or healthcare professionals, as appropriate and available. In the event that local or regional capacity to provide medical care during a pandemic is exceeded, DSHS may activate the state Medical Shelter Plan. This plan enables the use of state supported medical shelters as alternate or palliative care facilities. DSHS and the Strategic National Stockpile (SNS) also store a limited amount of RPDs for the healthcare workforce and mechanical ventilators for the critically ill. When DSHS executive


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leadership and advisors decide it is appropriate, state resources are made available and federal resources may be requested. Decisions may have to be made to ensure that certain high risk populations are prioritized to receive the medical care and countermeasures, based on available epidemiologic data. A system for distributing medical countermeasures through centers and providers around the state, including healthcare provider offices and pharmacies, might need to be established. PHARMACEUTICAL INTERVENTIONS Vaccine When a new strain of influenza appears, available vaccines might confer partial immunity. For this reason, and also because full immunity is not achieved until about two weeks following vaccination, immunization against seasonal influenza is always recommended. When a novel non-influenza respiratory virus strain emerges, there will likely be little if any immunity in the population. Vaccination against seasonal influenza would not be expected to confer even partial immunity against the novel virus, but seasonal influenza immunization should be encouraged regardless because of the potential for serious illness resulting from dual infection. In a normal influenza season, CDC distributes vaccine to states for public sector use, based on each state’s influenza vaccine order submission. Private sector vaccine is ordered directly from the manufacturer or distributors. In Texas, public sector influenza vaccine is available for uninsured adults aged 19 years and older at DSHS regional clinics. For children 18 years of age or younger meeting certain eligibility requirements, influenza vaccine is available through the Texas Vaccines for Children (TVFC) providers. To be eligible for the TVFC program, children must be Medicaid-eligible, Alaskan Native, American Indian, enrolled in the Texas Children’s Health Insurance Plan (CHIP) and a patient at a CHIP-billing facility, or be uninsured or underinsured. DSHS public sector influenza vaccine orders, which are determined through a survey of DSHS regional office staff and TVFC providers, are submitted to CDC. The DSHS Immunization Branch monitors the public vaccine supply, both at the state and national levels, through direct communication with CDC and tracking of doses ordered and administered by the DSHS provider network, including TVFC providers and DSHS regional clinics. In a respiratory virus pandemic situation, when available vaccines are ineffective or unavailable, it may take many months for an effective vaccine to be developed and distributed. If this occurs, there may be limited amounts of vaccine made available at periodic intervals. As a pandemic escalates, CDC would issue recommendations on priority groups for vaccination. DSHS would then consult its Vaccine Advisory Committee (VAC), which comprises DSHS medical experts, to determine prioritization of vaccination efforts based on CDC recommendations, as well as available medical evidence and disease surveillance data. The Immunization Branch would then determine the vaccine allocation and distribution plan based on the prioritizations recommended and consideration of high-risk populations served by medical providers, the number of vaccine doses available for distribution, and adjustments of provider vaccine orders. It is assumed that CDC would allocate vaccine to the states based on population size and availability of vaccine. Vaccine distribution would be conducted through normal distribution procedures for order submissions and direct vaccine shipments to medical providers. If the DSHS provider network is determined to be inadequate for meeting the plan, a system for distributing vaccine through pharmacies and private medical providers may be established, or the state’s SNS plan may be activated. If necessary, the DSHS Pharmacy Branch may store and redistribute vaccine.


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The DSHS Immunization Branch would be the source of vaccine distributed in the state. Submitted, evaluated, and approved vaccine orders would be sent to the federal vaccine distribution center, which would ship vaccine directly to providers. The Immunization Branch would also track the shipment and administration of vaccine, using existing seasonal vaccine ordering systems and ImmTrac, the statewide immunization registry. The DSHS Immunization Branch is also responsible for tracking of vaccine adverse events and would continue to do so during a pandemic. A DSHS Vaccine Adverse Event Reporting System (VAERS) clinical team responds to vaccine safety concerns and serves as a safety resource for healthcare providers and the general public. The Vaccine Safety Coordinator/VAERS Coordinator is the primary liaison between the state and CDC. Additionally, the Texas Poison Control Center Network (TPCN) can be alerted and respond to adverse event calls. The health professionals at the poison control centers would provide treatment recommendations or refer calls to local emergency departments, as appropriate. In addition, the DSHS Immunization Branch would receive email notifications (at a mailbox set up for a pandemic) of TPCN vaccine-related calls. When TPCN staff follows back with emergency departments, they would encourage hospital staff to complete a VAERS form and submit it to DSHS, if this had not already been done. Antiviral medications Persons exposed to influenza or with early symptoms of illness might avoid or reduce the severity of illness by taking an appropriate influenza antiviral (AV) medication. Some influenza antiviral medications are stored within the state, and more are stored at SNS sites around the country. For non-influenza viral respiratory outbreaks or potential outbreaks, particularly those that are novel, DSHS will communicate information from CDC and other experts regarding any effective and available antiviral medications. The possibility exists that a novel influenza or other respiratory virus could emerge and be found resistant to most or all available antiviral medications. Should this occur, any alternative treatment information provided to DSHS Central Office would be communicated directly to the medical community and on the DSHS website. Alternative treatment options might include an experimental treatment (antiviral or other) that is not approved by the FDA. Physicians would need to make a “compassionate use request” directly to the medication’s manufacturer. Other pharmaceutical interventions Other pharmaceutical interventions, such as other medications, regimens or certain medical supplies (e.g., syringes, personal protective equipment) may be indicated depending on the severity and type of illness and resource availability. Medications and medical products may be available through the SNS or other vendors. A system for procurement, receipt, storage, distribution, tracking, returns, and disposition of pharmaceutical products may be required.


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V. OPERATIONAL LEVELS AND RESPONSE ACTIVITIES The operational activities of this pandemic influenza and other respiratory viruses control plan involve the following five levels: routine, enhanced, increased readiness, escalated, and emergency response. These operational levels are determined by assessments of human case counts, geographic distribution of cases, travel-related status of human cases, presence of sustained human-to-human transmission, complexity of investigations, and level of public or media attention. The specific data used to establish the current operational level should be determined, in part, by the jurisdiction to which it applies. Jurisdictional staff can use the data collected to estimate the level of pandemic influenza or other respiratory virus activity and determine the appropriate level of response. Appropriate responses for DSHS and local jurisdictions at each operational level are also included. Some jurisdictions will not have data for all of the variables. Nonetheless, each jurisdiction will have a tool it can use to guide decision making regarding education of the general public and healthcare providers, implementation of control measures, and addition of enhanced surveillance activities. Each operational level is first defined by the existing conditions for the variables specified above. All of these conditions do not need to be attained in order for a specific operational level to be reached. In addition, a change in a single condition does not necessarily cause the operational level to be raised. The conditions should be considered together when determinations are being made on appropriate response activities. This plan does not include basic activities that are necessary in order to maintain readiness, such as annual reviews of planning documents, grant writing and other grant activities, training in surveillance and response, and related activities. It is expected that DSHS Central Office and HSRs, as well as LHDs, will be conducting these preparatory activities without them being specifically mentioned herein. As noted above, investigations are classified in this document as either complex or non-complex. A complex investigation is defined as an investigation in which one or more investigation activities (e.g., primary case investigations, contact investigations, control measures implementation, data analysis, laboratory testing, public relations) exceed the health department’s and/or program’s routine resources. This may result in the health department and/or program surging personnel and/or supplies, activating an ICS structure, and/or increasing coordination with other agencies. A non-complex investigation is defined as an investigation in which investigation activities are easily managed with routine health department or programmatic resources. A. LOCAL JURISDICTIONS, INCLUDING HEALTH SERVICE REGION

OFFICES CONDUCTING LOCAL HEALTH DEPARTMENT FUNCTIONS This section spans pages 10 through 20 and describes the response activities for local jurisdictions during the five phases mentioned above. B. CENTRAL OFFICE AND HEALTH SERVICE REGIONS This section spans pages 21 through 51 and describes the DSHS operational activities during the five phases mentioned above.

Operational Levels and Response Activities Local Jurisdictions including Health Service Region Offices Conducting Local Health Department Functions

Local Health Department Operational Levels and Indicators Routine Operations Enhanced Operations Increased Readiness

Operations Escalated Operations Emergency Response

Operations Texas, United States, International

Normal respiratory virus season

Sporadic cases of human infection internationally without sustained human-to-human transmission

Sustained human-to-human transmission internationally

First domestically imported case (sustained transmission internationally) anywhere in the US

Sustained human-to-human transmission anywhere in the US

Texas, United States, International


Sporadic, imported case(s) or isolated case(s) with no secondary transmission in Texas

Isolated, non-imported case (no associated sustained transmission) in Texas requiring complex investigation

Multiple, non–imported-related cases in Texas

Widespread cases in Texas

Local Health Department


Single, imported case(s) with non-complex investigations

Single, non-imported case with complex investigations (e.g.: MERS-CoV)

Multiple cases requiring complex case investigations

Multiple cases requiring complex case investigations



Single case in an adjacent jurisdiction or within the same HSR

Single case in the local jurisdiction or an adjacent jurisdiction

Multiple cases in the local jurisdiction or an adjacent jurisdiction

Multiple cases in the local jurisdiction or an adjacent jurisdiction


No to moderate levels of public or media attention


Increased levels of public or media attention

High to exceptional levels of public or media attention


The purpose of this chart is to describe characteristics which may be considered when determining the appropriate operational level. These characteristics should be considered in totality, along with other available information. All characteristics do not need to be reached before moving to the next higher operational level, a change in any one characteristic does not necessarily result in an increase to the next operational level. The operational level should be determined by the current situation.


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ROUTINE OPERATIONS: Routine activities are focused on surveillance, education, and prevention during a normal respiratory virus season (e.g., no novel respiratory viruses are circulating or have been detected). Routine operations are handled at the programmatic level. CONDITIONS IN LOCAL JURISDICTION No confirmed human cases of novel influenza or other respiratory virus identified in Texas No increased complexity of investigations for respiratory illnesses No to moderate public or media attention related to influenza or other respiratory virus RESPONSE ACTIVITIES Leadership Maintain regular communications with communicable disease control and prevention staff and

ensure that leadership staff in local jurisdictions within the jurisdictional area is aware of current conditions statewide

Promote and encourage preparedness activities within the jurisdiction for influenza and other viruses with pandemic potential

Laboratory Conduct seasonal influenza surveillance testing and support statewide influenza laboratory

surveillance activities, as described in the Texas Influenza Surveillance Handbook (if local health department [LHD] has a laboratory)

Communicable Disease Control and Prevention Surveillance and Epidemiology Conduct influenza and influenza-like illness (ILI) surveillance, analyze the data, and share the

findings using routine reporting mechanisms, as described in the Texas Influenza Surveillance Handbook

Submit specimens to the appropriate public health laboratory for any suspect human cases of novel influenza or other respiratory viruses of concern and monitor laboratory reports indicating possible confirmed cases, as described in the Texas Influenza Surveillance Handbook

Monitor laboratory influenza reports and immediately investigate any suspect human cases of novel influenza or other respiratory viruses of concern, as described in the DSHS Emerging and Acute Infectious Disease Branch (EAIDB) Investigation Guidance for Novel Influenza (request from DSHS EAIDB)

Notify the Health Service Region office (HSR), for LHDs, or DSHS Central Office, for HSRs, when outbreaks of respiratory illnesses are identified or when suspect cases of novel influenza or other respiratory viruses of concern are being investigated

Vaccine Program Promote seasonal influenza vaccinations for everyone six months old and older, based on

current recommendations Provide seasonal influenza vaccinations to health department staff Communications Conduct appropriate community outreach and public education Communicate with healthcare providers and other partners


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Emergency Preparedness Promote influenza and other respiratory disease prevention, such as social distancing, hand

hygiene, and respiratory etiquette


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ENHANCED OPERATIONS: Enhanced activities are focused on surveillance, education, and prevention, as well as response to single imported cases of novel influenza or other respiratory virus with pandemic potential. Enhanced operations may be handled at the programmatic level or through virtual activation of the operations center. CONDITIONS IN LOCAL JURISDICTION Sporadic confirmed, travel-related human cases of novel influenza or other respiratory virus

detected in the local jurisdiction or in an adjacent jurisdiction No secondary transmission of novel influenza or other respiratory virus Non-complex investigation for human cases of novel influenza or other respiratory virus No to moderate public or media attention related to influenza or other respiratory viruses RESPONSE ACTIVITIES Leadership Continue to: Maintain regular communications with communicable disease control and prevention staff and


Promote and encourage preparedness activities within the jurisdiction for influenza and other viruses with pandemic potential

Laboratory Ensure select specimens are forwarded to a Laboratory Response Network (LRN) laboratory

or to the DSHS laboratory, as requested by DSHS Emerging and Acute Infectious Disease Branch (EAIDB)

Continue to: Conduct seasonal influenza surveillance testing and support statewide influenza laboratory

surveillance activities, as described in the Texas Influenza Surveillance Handbook (if local health department [LHD] has a laboratory)

Communicable Disease Control and Prevention Surveillance and Epidemiology Immediately notify DSHS (by phone) of confirmed human cases of novel influenza or other

respiratory viruses of concern and, when applicable, through the National Electronic Disease Surveillance System (NEDSS) within one business day of case confirmation

Conduct contact investigations, if requested by DSHS EAIDB Enhance surveillance for influenza-like illness (ILI) for at least four (4) weeks following

identification of novel influenza or other respiratory virus by actively following up with routine reporters

Request DSHS assistance with appropriate needs, including investigations and data entry Continue to: Conduct influenza and ILI surveillance, analyze the data, and share the findings using routine

reporting mechanisms, as described in the Texas Influenza Surveillance Handbook Submit specimens to the appropriate public health laboratory for any suspect human cases of

novel influenza or other respiratory viruses of concern and monitor laboratory reports


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indicating possible confirmed cases, as described in the Texas Influenza Surveillance Handbook

Immediately investigate any suspect human cases of novel influenza or other respiratory viruses of concern, as described in the DSHS EAIDB Investigation Guidance for Novel Influenza (request from DSHS EAIDB)

Vaccine Program Continue to: Promote seasonal influenza vaccinations for everyone six months old and older, based on

current recommendations Provide seasonal influenza vaccinations to health department staff

Communications Communicate and coordinate with local partners Provide information to local media representatives and encourage its distribution Partner with local community-based organizations to target high-risk populations for

appropriate outreach campaigns Enhance community access to information Continue to: Conduct community outreach and public education Communicate with healthcare providers Emergency Preparedness Determine whether current response can be handled at a programmatic level or through a

virtual activation of the operations center and proceed accordingly In collaboration with DSHS EAIDB, discuss non-pharmaceutical interventions to be

implemented, if any Communicate with all partners within the jurisdiction to maintain situational awareness Continue to: Promote influenza and other respiratory disease prevention, such as social distancing, hand

hygiene, and respiratory etiquette


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INCREASED READINESS OPERATIONS: Increased readiness activities are adjusted in response to complex investigations into isolated novel influenza or other respiratory virus cases. Increased readiness operations may be handled through a virtual or limited activation of the operations center. CONDITIONS IN LOCAL JURISDICTION Sporadic confirmed, non–travel-related human cases of novel influenza or other respiratory

virus detected in the local jurisdiction or in an adjacent jurisdiction No sustained transmission of novel or other respiratory virus for local jurisdiction cases Complex investigations for human cases of novel influenza or other respiratory virus Increased public or media attention related to influenza or other respiratory viruses RESPONSE ACTIVITIES

Leadership Establish regular communication with Health Service Region (HSR) leadership, for local

health departments (LHDs), or DSHS Central Office leadership, for HSRs Increase preparedness activities within the jurisdiction for influenza and other viruses with

pandemic potential Continue to: Maintain regular communications with communicable disease control and prevention staff and


Laboratory Ensure select specimens are forwarded to a Laboratory Response Network (LRN) laboratory

or to the DSHS laboratory, as requested by DSHS Emerging and Acute Infectious Disease Branch (EAIDB)

Continue to: Conduct seasonal influenza surveillance testing and support statewide influenza laboratory

surveillance activities, as described in the Texas Influenza Surveillance Handbook (if LHD has a laboratory)

Communicable Disease Control and Prevention Surveillance and Epidemiology DSHS HSR staff should assist LHDs, as needed Conduct data entry as needed and coordinate workflow for real-time data entry into National

Electronic Disease Surveillance System (NEDSS), as requested Analyze, map, and report influenza or other respiratory virus cases of concern data weekly Continue to: Conduct influenza and influenza-like illness (ILI) surveillance, analyze the data, and share the


Submit specimens to the appropriate public health laboratory for any suspect human cases of novel influenza or other respiratory viruses of concern and monitor laboratory reports indicating possible confirmed cases, as described in the Texas Influenza Surveillance Handbook


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Immediately notify DSHS by phone of confirmed human cases of novel influenza or other respiratory viruses of concern and, when applicable, through the NEDSS within one business day of case confirmation

Conduct contact investigations, if requested by DSHS EAIDB Enhance surveillance for ILI for at least four (4) weeks following identification of novel

influenza or other respiratory virus by actively following up with routine reporters Request DSHS assistance with appropriate needs, including investigations and data entry Vaccine Program Estimate near future needs, and order vaccine, if appropriate and available Continue to: Promote seasonal influenza vaccinations for everyone six months old and older, based on

current recommendations Provide seasonal influenza vaccinations to health department staff

Communications Continue to: Communicate and coordinate with local partners Provide information to local media representatives and encourage its distribution Partner with local community-based organizations to target high-risk populations for

appropriate outreach campaigns Enhance community access to information Conduct community outreach and public education Communicate with healthcare providers Emergency Preparedness Determine whether current response can be handled through a virtual or limited activation of

the operations center and proceed accordingly Implement and monitor non-pharmaceutical interventions Assess supplies on hand and order additional, if needed Continue to: Communicate with all partners within the jurisdiction to maintain situational awareness


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ESCALATED OPERATIONS: Escalated activities are adjusted in response to complex investigations into multiple novel influenza or other respiratory virus cases. Escalated operations are handled through a limited to full activation of the operations center. CONDITIONS IN LOCAL JURISDICTION Multiple confirmed, non–travel-related human cases of novel influenza or other respiratory

virus detected in the local jurisdiction or in an adjacent jurisdiction Sustained transmission of novel influenza or other respiratory virus internationally Complex investigations for human cases of novel influenza or other respiratory virus High levels of public or media attention related to influenza or other respiratory virus RESPONSE ACTIVITIES Leadership Continue to: Maintain regular communications with Health Service Region (HSR) leadership, for local

health department (LHDs) or DSHS Central Office leadership, for HSRs Increase preparedness activities within the jurisdiction for influenza and other viruses with

pandemic potential Maintain regular communications with communicable disease control and prevention staff and


Laboratory Prepare to receive more than the usual number of specimens Adjust the amount of testing done, according to DSHS Emerging and Acute Infectious

Disease (EAIDB) recommendations (e.g., test more specimens or limit testing to specimens meeting criteria specified by DSHS EAIDB)

Continue to: Ensure select specimens are forwarded to a Laboratory Response Network (LRN) laboratory

or to the DSHS laboratory, as requested by DSHS EAIDB Conduct seasonal influenza surveillance testing and support statewide influenza laboratory

surveillance activities, as described in the Texas Influenza Surveillance Handbook (if LHD has a laboratory)

Communicable Disease Control and Prevention Surveillance and Epidemiology Request additional resources, as needed for investigations or data entry Conduct case and contact investigations until directed otherwise by DSHS EAIDB Continue to: Conduct influenza and influenza-like illness (ILI) surveillance, analyze the data, and share the


Submit specimens to the appropriate public health laboratory for any suspect human cases of novel influenza or other respiratory viruses of concern and monitor laboratory reports


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Immediately notify DSHS by phone of confirmed human cases of novel influenza or other respiratory viruses of concern and, when applicable, through the National Electronic Disease Surveillance System (NEDSS) within one business day of case confirmation

Enhance surveillance for ILI for at least four (4) weeks following identification of novel influenza or other respiratory virus cases by actively following up with routine reporters (consult DSHS EAIDB for criteria for continuing enhanced surveillance)

Conduct data entry as needed and coordinate workflow for real-time data entry into NEDSS, as requested

Analyze, map, and report influenza or other respiratory viruses of concern data weekly Vaccine Program Prepare for possible mass vaccination clinics, if indicated Continue to: Estimate near future needs, and order vaccine, if appropriate and available Promote seasonal influenza vaccinations for everyone six months old and older, based on

current recommendations Provide seasonal influenza vaccinations to health department staff Communications Collaborate with HSR and DSHS EAIDB staff to establish a set schedule for officially releasing

updated case counts publicly Notify local hospitals, clinics, schools, long term care facilities, and healthcare providers of the

situation Ensure state or national health alerts are forwarded, as appropriate Continue to: Communicate and coordinate with local partners Provide information to local media representatives and encourage its distribution Partner with local community-based organizations to target high-risk populations for

appropriate outreach campaigns Enhance community access to information Conduct community outreach and public education Communicate with healthcare providers Emergency Preparedness Determine whether current response can be handled through a limited or full activation of the

operations center and proceed accordingly Coordinate with appropriate regional and state responding agencies Continue to: Monitor non-pharmaceutical interventions Assess supplies on hand and order additional, if needed Communicate with all partners within the jurisdiction to maintain situational awareness


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EMERGENCY RESPONSE OPERATIONS: Emergency response activities are highly elevated and include additional activities to control a pandemic or widespread epidemic of novel influenza or other respiratory virus. Emergency operations are handled through a full activation of the operations center. CONDITIONS IN LOCAL JURISDICTION Multiple confirmed, non–travel-related human cases of novel influenza or other respiratory

virus detected in the local jurisdiction or in an adjacent jurisdiction Sustained transmission of novel influenza or other respiratory virus inside the US Widespread human cases of novel influenza or other respiratory virus in Texas Complex investigations for human cases of novel influenza or other respiratory virus Exceptional levels of public or media attention related to influenza or other respiratory virus Multiple jurisdictions with multiple HSRs reporting emergency response activities RESPONSE ACTIVITIES Leadership Support emergency preparedness activities within the jurisdiction for influenza and other

viruses with pandemic potential Continue to: Maintain regular communications with Health Service Region (HSR) leadership, for local

health departments (LHDs), or DSHS Central Office leadership, for HSRs Maintain regular communications with communicable disease control and prevention staff and


Laboratory Continue to: Prepare to receive more than the usual number of specimens Adjust the amount of testing done, according to DSHS Emerging and Acute Infectious

Disease Branch (EAIDB) recommendations (e.g., test more specimens or limit testing to specimens meeting criteria specified by DSHS EAIDB)

Ensure select specimens are forwarded to a Laboratory Response Network (LRN) laboratory or to the DSHS laboratory, as requested by DSHS EAIDB

Communicable Disease Control and Prevention Surveillance and Epidemiology Collect aggregate surveillance data on hospitalizations and deaths Continue to: Conduct case and contact investigations until directed otherwise by DSHS EAIDB Conduct influenza and influenza-like illness (ILI) surveillance, analyze the data, and share the


Submit specimens to the appropriate public health laboratory for any suspect human cases of novel influenza or other respiratory viruses of concern and monitor laboratory reports


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Immediately notify DSHS (by phone) of confirmed human cases of novel influenza or other respiratory viruses of concern and, when applicable, through the National Electronic Disease Surveillance System (NEDSS) within one business day of case confirmation

Conduct data entry as needed and coordinate workflow for real-time data entry into NEDSS, as requested

Analyze, map, and report influenza or other respiratory viruses of concern data weekly Vaccine Program Conduct and/or assist with mass vaccination clinics and order vaccine, as appropriate Continue to: Estimate near future needs, and order vaccine, if appropriate and available Promote seasonal influenza vaccinations for everyone six months old and older, based on

current recommendations Provide seasonal influenza vaccinations to health department staff Communications Continue to: Communicate and coordinate with local partners Provide information to local media representatives and encourage its distribution Partner with local community-based organizations to target high-risk populations for

appropriate outreach campaigns Enhance community access to information Conduct community outreach and public education Communicate with healthcare providers Collaborate with HSR and DSHS EAIDB staff to establish a set schedule for officially releasing

updated case counts publicly Notify local hospitals, clinics, schools, long term care facilities, and healthcare providers of the

situation Ensure state or national health alerts are forwarded, as appropriate

Emergency Preparedness Fully activate the operations center and transition all appropriate response activities to the

operations center Declare a local disaster, if appropriate Request state or federal resources, as applicable and according to protocols Coordinate command and control with the Regional Health and Medical Operations Center

(RHMOC) Continue to: Monitor non-pharmaceutical interventions Assess supplies on hand and order additional, if needed Communicate with all partners within the jurisdiction to maintain situational awareness Coordinate with appropriate regional and state responding agencies

Operational Levels and Response Activities Central Office and Health Service Regions

DSHS Operational Levels and Indicators Routine Operations Enhanced Operations Increased Readiness

Operations Escalated Operations Emergency Response

Operations United States and International


Sporadic cases of human infection internationally without sustained human-to-human transmission

Sustained human-to-human transmission internationally

First non–international travel-related case anywhere in the US

Sustained human-to-human transmission anywhere in the US

Texas Normal respiratory virus season

Sporadic manageable imported-related case with non-complex investigations

Single non–imported-related case with complex contact investigation (e.g.: MERS-CoV)

Multiple non-imported-related cases with complex investigations within a defined geographic area

Multiple widespread non–imported-related cases with complex investigations

Texas Normal respiratory virus season

Single imported-related case with no secondary cases

Single non–imported-related case with complex contact investigation (e.g.: MERS-CoV)

Multiple non-imported-related cases with complex investigations within a defined geographic area

Multiple widespread non–imported-related cases with complex investigations

Texas No to moderate levels of public or media attention


Increased levels of public or media attention



Texas No local operations centers activated

0 to 1 local operations centers activated within single HSR

Multiple local operations centers activated within a single or adjacent HSR

Multiple local operations centers activated within multiple HSRs (includes non-public health operations)

Multiple local operations centers activated within multiple HSRs (includes non-public health operations)

The purpose of this chart is to describe characteristics which may be considered when determining the appropriate operational level. These characteristics should be considered in totality, along with other available information. All characteristics do not need to be reached before moving to the next higher operational level, a


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ROUTINE OPERATIONS: Routine activities are focused on surveillance, education, and prevention during a normal respiratory virus season (e.g., no novel respiratory viruses with pandemic potential are circulating or have been detected). Routine operations are handled at the programmatic level. CONDITIONS IN STATE No confirmed human cases of novel influenza or other respiratory viruses having pandemic

potential identified in Texas No increased complexity of investigations for respiratory virus cases No to moderate public or media attention related to influenza or other respiratory viruses

having pandemic potential No jurisdictions reporting emergency response operations No Texas Animal Health Commission (TAHC) animal case reports of respiratory viruses

having pandemic potential RESPONSE ACTIVITIES

DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES HSR Director Maintain awareness for influenza and other respiratory viruses through regular

communications with staff Ensure that leadership staff in local jurisdictions is aware of current conditions statewide Promote and encourage preparedness within the jurisdiction for influenza and other viruses

with pandemic potential Surveillance and Epidemiology Conduct routine surveillance and epidemiology activities in counties where the HSR office

conducts these functions, as described in the Texas Influenza Surveillance Handbook Investigate any suspect human cases of novel influenza or other respiratory viruses with

pandemic potential immediately and notify DSHS Central Office, as described in the Emerging and Acute Infectious Disease Investigation Guidelines

Provide subject matter expertise, guidance, and support to local health department (LHD) staff, as needed

Coordinate influenza surveillance and reporting activities across all counties in the HSR Immunization Promote seasonal influenza vaccine for everyone six months of age or older, based on

current recommendations, and conduct other influenza prevention activities Provide educational information, outreach, pamphlets, newspaper articles to public health

clinic sites Vaccinate HSR staff Vaccinate qualifying Texas Vaccine for Children (TVFC) and adult clients served by local

public health clinic sites


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Recruit providers to TVFC Program and ImmTrac Manage immunization operations by monitoring vaccine inventory, approving vaccine

orders, and providing technical assistance to public health clinics, LHDs, and TVFC provider offices

Emergency Preparedness Serve as the coordinating entity for Emergency Support Function #8 (ESF-8), Public Health

and Medical Services to support the Disaster District Committees (DDCs) within the HSR Identify and train staff to support local public health and medical response and to serve in

the DDCs and/or Regional Health and Medical Operations Center (RHMOC) Maintain and update RHMOC operating procedures Maintain regional tactical communications equipment Maintain cache of antivirals, if appropriate Maintain regional Strategic National Stockpile (SNS) and other appropriate plans Maintain routine communication with the Laboratory Response Network (LRN) Maintain routine communication with LHDs, Texas Division of Emergency Management

(TDEM), and appropriate local emergency management COMMUNITY PREPAREDNESS SECTION (CPS) Serve as the primary state coordinating agency for Emergency Support Function #8 (ESF-

8), Public Health and Medical Services Identify and train staff to serve in the State Medical Operations Center (SMOC) Incident

Command System (ICS) structure, during an activation Maintain and update state level preparedness and response documents (e.g., SMOC

Operations Manual, state level response operating guides and preparedness plans, Memorandums of Understanding [MOUs], contracts, private pharmacy contact lists)

Maintain SMOC tactical communications equipment and communications platforms (Public Health Information Network [PHIN], Emergency Management Resource, Web Emergency Operations Center [WebEOC])

Plan for the procurement, storage, and distribution of state controlled caches of antiviral medications, (non-seasonal) influenza vaccines, and other medical assets for pandemic response

Maintain routine communication with DSHS HSR Directors, Regional Preparedness Program Managers, and TDEM preparedness staff

CENTER FOR POLICY AND EXTERNAL AFFAIRS (CPEA)

Respond to respiratory virus and influenza-like illness (ILI)related media calls, legislative

requests, and questions from the public Monitor news media Update DSHS website, including programmatic and media webpages, to include any novel

respiratory virus information and relevant precautions, as appropriate Promote influenza and other viral respiratory illness prevention activities Identify and train public information officer (PIO) and government liaison to serve in the

SMOC during an activation


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DIVISION FOR DISEASE CONTROL AND PREVENTION SERVICES EMERGING AND ACUTE INFECTIOUS DISEASE BRANCH (EAIDB) Coordinate influenza and other respiratory virus surveillance and investigations, as

described in the Texas Influenza Surveillance Handbook Monitor and maintain the National Electronic Disease Surveillance System (NEDSS) Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to HSR and LHD staff on investigations of novel

influenza or other respiratory viruses with pandemic potential Maintain regular communication with U.S. Centers for Disease Control and Prevention

(CDC) Identify and train liaison to serve in the SMOC during an activation LABORATORY SERVICES SECTION Conduct influenza and other respiratory virus surveillance testing, as described in the Texas

Influenza Surveillance Handbook Consult with EAIDB regarding testing of non-routine specimens Identify and train liaison to serve in the SMOC during an activation IMMUNIZATION BRANCH Promote seasonal vaccination for everyone six months of age or older, based on current

recommendations Analyze seasonal vaccination rates Develop, produce, and distribute educational information, outreach, pamphlets, radio spots,

posters, etc. Survey the HSRs and TVFC providers annually for projected vaccine needs for the

upcoming season Submit estimated vaccine order for the upcoming season to CDC Facilitate seasonal vaccination of health department staff and qualifying public sector clients Recruit new providers for TVFC and ImmTrac Collaborate with EAIDB to monitor surveillance findings Monitor vaccine safety with the Vaccine Adverse Event Reporting System (VAERS) and the

Texas Poison Control Network Identify and train liaison to serve in the SMOC during an activation PHARMACY BRANCH Procure, receive, store, and distribute seasonal influenza vaccine for HSRs, LHDs, and

private providers in coordination with the Immunization Branch Provide seasonal influenza vaccine and medical supplies for DSHS employee immunization

clinics Provide oversight to regional Class D pharmacies and pharmaceutical guidance to HSRs

and LHDs Identify and train liaison to serve in the SMOC during an activation


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ZOONOSIS CONTROL BRANCH (ZCB) Regularly communicate with TAHC and other animal health partners Identify and train liaison to serve in the SMOC during an activation


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ENHANCED OPERATIONS: Enhanced activities are focused on surveillance, education, and prevention, as well as response to single imported cases of novel influenza or other respiratory virus with pandemic potential. Enhanced operations may be handled at the programmatic level or through virtual activation of the operations center. CONDITIONS IN STATE Sporadic confirmed, isolated, travel-related human case of novel influenza or other

respiratory viruses detected in Texas No secondary transmission of novel influenza or other respiratory viruses in Texas No sustained human-to-human transmission of novel influenza or other respiratory virus

internationally Non-complex investigations for human cases or contacts of novel influenza or other

respiratory viruses No to moderate public or media attention related to influenza and other respiratory viruses No to one jurisdictions reporting emergency response operations Reports from Texas Animal Health Commission (TAHC) of animal case reports of

respiratory viruses having pandemic potential with no known transmission to humans RESPONSE ACTIVITIES

DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES HSR Director Continue to: Maintain awareness for influenza and other respiratory viruses through regular


with pandemic potential Surveillance and Epidemiology Provide updates to local health departments (LHDs) and to providers in counties where the

HSR conducts surveillance and epidemiology functions Ensure guidance from the Emerging and Acute Infectious Disease Branch (EAIDB) and the

Community Preparedness Section (CPS) reaches LHD staff Enhance surveillance for influenza-like illness (ILI) for at least four (4) weeks or two (2)

incubation periods, whichever is longer, following identification of novel influenza or other respiratory virus by actively following up with routine reporters to ensure timely reports

Assist jurisdictions with case investigations, data entry, and other surge capacity, as requested

Continue to: Conduct routine surveillance and epidemiology activities in counties where the HSR office

conducts these functions, as described in the Texas Influenza Surveillance Handbook


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Investigate any suspect human cases of novel influenza or other respiratory viruses with pandemic potential immediately and notify DSHS Central Office, as described in the Emerging and Acute Infectious Disease Investigation Guidelines

Provide subject matter expertise, guidance, and support to LHD staff, as needed Coordinate influenza surveillance and reporting activities across all counties in the HSR Immunization Continue to: Promote seasonal influenza vaccine for everyone six months of age or older, based on



public health clinic sites Recruit providers to TVFC Program and ImmTrac Manage immunization operations by monitoring vaccine inventory, approving vaccine


Emergency Preparedness Determine whether current response can be handled at a programmatic level or through a

virtual activation of the Regional Health and Medical Operations Center (RHMOC) to support the affected Disaster District Committees (DDCs)

Assign pre-identified, trained staff to support local public health and medical response and to serve in the RHMOC and/or DDCs

Develop and distribute Incident Action Plans (IAPs), Situation Reports (SitReps), and any associated documents for each operational period, as directed by the RHMOC Director, if RHMOC is activated

Ensure federal and state guidance reaches response partners, including the regional healthcare coalitions and local emergency management

Provide DSHS Central Office with information on non-pharmaceutical interventions being discussed or implemented in the HSR

Communicate with other internal partners to maintain situational awareness Encourage hospitals and congregate care settings to review and update their prevention

and control procedures Continue to: Serve as the coordinating entity for Emergency Support Function #8 (ESF-8), Public Health

and Medical Services for the DDCs within the HSR Maintain routine communication with LHDs, Texas Division of Emergency Management

(TDEM) personnel and appropriate local emergency management COMMUNITY PREPAREDNESS SECTION (CPS) Determine if the current response can be managed effectively without a full activation of the

State Medical Operations Center (SMOC); alternatives include managing operations at the programmatic level or through a virtual activation of the SMOC

Assess the possible need for distribution of antiviral medications, influenza vaccine,


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personal protective equipment (PPE), and other medical assets for pandemic response, in coordination with appropriate DSHS subject matter exerts (SMEs)

Consider activating healthcare resource reporting, including Hospital Available Beds for Emergencies and Disasters (HAvBED) and ventilators

Discuss and/or assess non-pharmaceutical intervention implementation Establish regular communication with private vendors and community pharmacies and other

private sector partners that provide medical resources Coordinate a review of roles and responsibilities with all participating DSHS partners and

stakeholders If the SMOC is activated: Assign and provide pre-identified, trained staff to the SMOC Incident Command System

(ICS) structure Coordinate with appropriate HSRs to activate the RHMOC in support of the DDCs in

affected regions, as needed Establish event reporting in Web Emergency Operations Center (WebEOC) and update Operationalize appropriate state level preparedness and response documents (e.g., SMOC


Develop and distribute IAPs, SitReps, Dashboards, and any associated documents for each operational period, as directed by the SMOC Director

Establish and maintain SMOC conference call schedules to keep appropriate public health and medical partners informed (e.g., HSRs, LHDs, RHMOCs, Emergency Operation Centers [EOCs], Regional Advisory Councils [RACs])

Coordinate with partners to create status and update reports for DSHS leadership, as needed

Continue to: Serve as the primary state coordinating agency for Emergency Support Function #8 (ESF-

8), Public Health and Medical Services Maintain routine communication with DSHS HSR Directors, Regional Preparedness

Program Managers and TDEM preparedness staff


Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Initiate coordination with LHD and HSR Public Information Officers (PIOs) Assign pre-identified, trained PIO and government liaison to serve in the SMOC Continue to: Respond to respiratory virus and ILI-related media calls, legislative requests, and questions

from the public Monitor news media Update DSHS website, including programmatic and media webpages, to include any novel

respiratory virus information, relevant precautions, and Texas case count, if applicable Promote influenza and other viral respiratory illness prevention activities

DIVISION FOR DISEASE CONTROL AND PREVENTION SERVICES


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EMERGING AND ACUTE INFECTIOUS DISEASE BRANCH (EAIDB) Review case definitions, investigation forms, plans, and procedures Request targeted increases in specimen submissions, in collaboration with the Laboratory

Services Section Provide updates to HSRs, LHDs, providers, and others, as appropriate Assist jurisdictions with case investigations, data entry, and other surge capacity, as

requested Assign pre-identified and trained liaison to serve in the SMOC Continue to: Coordinate influenza and other respiratory virus surveillance and investigations, as

described in the Texas Influenza Surveillance Handbook Monitor and maintain National Electronic Disease Surveillance System (NEDSS) Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to HSR and LHD staff on investigations of novel


(CDC)

LABORATORY SERVICES SECTION Review seasonal influenza surveillance and laboratory protocols Complete verification of CDC-provided novel respiratory virus or variant influenza virus

protocols Assign pre-identified and trained liaison to serve in the SMOC Continue to: Conduct influenza and other respiratory virus surveillance testing, as described in the Texas

Influenza Surveillance Handbook Consult with EAIDB regarding testing of non-routine specimens IMMUNIZATION BRANCH Monitor and review vaccine development, if applicable Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Assign pre-identified and trained liaison to serve in the SMOC Continue to: Promote seasonal vaccination for everyone six months of age or older, based on current

recommendations Develop, produce and distribute educational information, outreach, pamphlets, radio spots,

posters, etc. Facilitate seasonal vaccination of health department staff and qualifying public sector clients Recruit new providers for TVFC and ImmTrac Collaborate with EAIDB to monitor surveillance findings Monitor vaccine safety with the Vaccine Adverse Event Reporting System (VAERS) and the

Texas Poison Control Network


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PHARMACY BRANCH Assign pre-identified and trained liaison to serve in the SMOC Continue to: Procure, receive, store, and distribute seasonal influenza vaccine for HSRs, LHDs, and



and LHDs ZOONOSIS CONTROL BRANCH (ZCB) Share surveillance data, in collaboration with EAIDB Assign pre-identified and trained liaison to serve in the SMOC Continue to: Regularly communicate with TAHC and other animal health partners


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INCREASED READINESS OPERATIONS: Increased readiness activities are adjusted in response to complex investigations into isolated cases of novel influenza or other respiratory virus with pandemic potential. Increased readiness operations may be handled through a virtual or limited activation of the operations center.

CONDITIONS IN STATE Single confirmed, non—travel-related human case of novel influenza or other respiratory

virus with pandemic potential detected in Texas Sustained transmission of novel influenza or other respiratory virus with pandemic potential

internationally Complex investigations for human cases of novel influenza or other respiratory virus with

pandemic potential Increased public or media attention related to influenza or other respiratory virus with

pandemic potential Multiple jurisdictions within the same or adjacent Health Service Region (HSR) reporting

emergency response operations Reports from Texas Animal Health Commission (TAHC) of animal cases of respiratory

viruses having pandemic potential, with sporadic transmission to humans RESPONSE ACTIVITIES

DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES HSR Director Communicate regularly with DSHS Central Office leadership Communicate regularly with local health authorities Prepare within the jurisdiction for influenza and other viruses with pandemic potential Hold regular discussions with regional preparedness managers and staff Continue to: Maintain awareness for influenza and other respiratory viruses through regular

communications with staff Ensure that leadership staff in local jurisdictions is aware of current conditions statewide Surveillance and Epidemiology Analyze and report influenza or other respiratory virus data weekly to DSHS HSR Director,

DSHS HSR Public Health Preparedness Manager, and Emerging and Acute Infectious Disease Branch (EAIDB)

Enhance surveillance for influenza-like illness (ILI) for at least four (4) weeks or two (2) incubation periods, whichever is longer, following identification of the last case of novel influenza or other respiratory virus

Actively follow up with routine reporters to ensure timely reports of ILI data and specimen submissions

Initiate laboratory surveillance of a targeted population as directed by EAIDB


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Continue to: Provide updates to local health departments (LHDs) and to providers in counties where the

HSR conducts surveillance and epidemiology functions Ensure guidance from EAIDB and the Community Preparedness Section (CPS) reaches

LHD staff Conduct routine surveillance and epidemiology activities in counties where the HSR office



Provide subject matter expertise, guidance, and support to LHD staff, as needed Coordinate influenza surveillance and reporting activities across all counties in the HSR Assist jurisdictions with case investigations, data entry, and other surge capacity, as

requested Immunization Coordinate with local jurisdictions in preparation for mass vaccination clinics, in coordination

with CPS Distribute DSHS guidance, based on U.S. Centers for Disease Control and Prevention

(CDC) recommendations, on prioritization of target groups for new influenza or other respiratory virus strain vaccine, if available

Coordinate strategic discussions about vaccine allocations Distribute information from DSHS Immunization Branch to Texas Vaccine for Children

(TVFC) providers and LHDs regarding high-risk populations, and vaccine allocation and distribution

Monitor and maintain inventory control and order additional supplies, as needed Develop a plan with other HSR staff to identify and recruit non-traditional vaccine providers Review plans with other HSR staff to receive, store, and distribute vaccines, medications,

biologics requiring refrigeration and/or medical supplies Activate plans for distribution of any available pre-pandemic vaccine Continue to: Promote seasonal influenza vaccine for everyone six months of age or older, based on


clinic sites Vaccinate HSR staff Vaccinate qualifying TVFC and adult clients served by local public health clinic sites Recruit providers to TVFC Program and ImmTrac Manage immunization operations by monitoring vaccine inventory, approving vaccine


Emergency Preparedness Determine whether current response can be handled through a virtual or limited activation of

the Regional Health and Medical Operations Center (RHMOC) to support the affected Disaster District Committees (DDCs)

Provide pre-identified, trained staff to support local public health and medical response and to serve in the RHMOC and/or DDCs


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Monitor Web Emergency Operations Center (WebEOC) and other emergency communication systems

Activate resource reporting, including Hospital Available Beds for Emergencies and Disasters (HAvBED) and ventilators, if not done already

Work with Immunizations to activate plans for distribution of any available pre-pandemic vaccine

Identify and verify location and operability of receiving, staging, and storage sites for federal antiviral distribution

Coordinate the preparation for and support of Point of Dispensing (POD) sites (medication and vaccine), as needed, in coordination with LHDs, clinicians, and pharmacies, if vaccine available

Continue to: Ensure federal and state guidance reaches response partners, including the regional

healthcare coalitions and local emergency management Provide DSHS Central Office with information on non-pharmaceutical interventions being

discussed or implemented in the HSR Communicate with other internal partners to maintain situational awareness Develop and distribute Incident Action Plans (IAPs), Situation reports (SitReps), and any

associated documents for each operational period, as directed by the RHMOC Director, if RHMOC activated

COMMUNITY PREPAREDNESS SECTION (CPS) Determine whether current response can be handled through a virtual or limited activation of

the State Medical Operations Center (SMOC) Provide pre-identified, trained staff to the SMOC Incident Command System (ICS) structure Coordinate with appropriate HSR to activate RHMOC in support of DDCs in affected regions Establish event reporting in WebEOC and update Ensure adherence to appropriate state level preparedness and response documents (e.g.,

SMOC Operations Manual, state level response operating guides and preparedness plans, Memorandums of Understanding [MOUs], contracts, private pharmacy contact lists)




Activate resource reporting, including HAvBED and ventilators Recommend implementation of non-pharmaceutical interventions Identify additional sources of antiviral medications, influenza vaccine, personal protective

equipment (PPE), and other medical assets for pandemic response, in coordination with appropriate DSHS subject matter experts (SMEs)

In consult with DSHS Executive Leadership, prepare to activate plans for allocation and distribution of any available vaccine and/or antiviral medications Identify and verify location and operability of receiving, staging, and storing (RSS) sites for federal antiviral distribution

Provide decision making recommendations for healthcare allocation of scarce resources Coordinate the preparation and support of POD sites (medication and vaccine), as needed,

in coordination with HSRs, LHDs, clinicians, and pharmacies


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Disseminate PPE guidance for responders and clinicians, in coordination with appropriate SMEs

Collect information from participating DSHS partners and stakeholders to identify the critical support elements and expectations

Request regular epidemiology updates from the EAIDB Coordinate regularly with the Center for Policy and External Affairs (CPEA) to ensure

consistent public messaging Continue to: Serve as the primary state coordinating agency for Emergency Support Function #8, ESF-8,

Public Health and Medical Services Maintain regular communication with private vendors and community pharmacies and other

private sector partners that provide medical resources


Provide pre-identified, trained Public Information Officer (PIO) and government liaison to serve in the SMOC, if requested

Consult with DSHS leadership and SMEs to assess need for emergency public information dissemination

Respond to increases in press, legislative, and LHD inquiries and address any misinformation

Respond to requests from the media, elected officials, and the public Determine size and scope of public awareness campaign, if needed Coordinate with other DSHS partners to establish a set schedule for releasing updated

Texas case counts publically Distribute information to public health, medical, and emergency management partners, as

appropriate Ensure that legislative leadership is aware of response status and provide pertinent

background information Translate emergency public information into Spanish and other languages, as appropriate Coordinate with LHD and HSR PIOs, and assess the need for Joint Information System

(JIS) Continue to: Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Update DSHS website, including programmatic and media webpages, to include any novel



EMERGING AND ACUTE INFECTIOUS DISEASES BRANCH (EAIDB) Review specimen submission and testing criteria and adjust if needed, in conjunction with

the Laboratory Services Section and the Epidemiology Advisory Group (EAG) Analyze and report seasonal, novel and/or pandemic influenza or other respiratory virus

data weekly, or as appropriate


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Enhance surveillance for ILI for at least four (4) weeks or two (2) incubation periods, whichever is longer, following identification of the last case of novel influenza or other respiratory virus


Work with health departments to initiate laboratory surveillance of targeted populations, as appropriate

Provide pre-identified, trained liaison to serve in the SMOC Continue to: Coordinate influenza and other respiratory virus surveillance and investigations, as


influenza or other respiratory viruses with pandemic potential Maintain regular communication with CDC Request targeted increases in specimen submissions, in collaboration with the Laboratory


requested LABORATORY SERVICES SECTION Review specimen submission and testing criteria and adjust if needed, in collaboration with

EAIDB and the EAG Conduct respiratory virus specimen testing based on established testing criteria, in

collaboration with EAIDB, referring to CDC when appropriate Maintain inventory control and order additional supplies, as needed Cross-train laboratory personnel, as needed Provide pre-identified, trained liaison to serve in the SMOC Continue to: Conduct influenza and other respiratory virus surveillance testing, as described in the Texas

Influenza Surveillance Handbook Consult with EAIDB regarding testing of non-routine specimens IMMUNIZATION BRANCH Communicate with CDC to determine a seasonal vaccine allocation and distribution pan,

which includes the identification and prioritization of priority high-risk populations based on surveillance data

Convene Vaccine Allocation Advisory Committee (VAAC) to determine high-risk populations for vaccine

Develop the seasonal vaccine allocation and distribution plan based on the identified high-risk and prioritized populations

Collaborate with medical providers that receive vaccine from DSHS to identify their high-risk populations and plan for potential seasonal vaccine distribution to these providers’ offices

Develop a plan to identify and recruit non-traditional medical providers for vaccine distribution and administration


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Provide pre-identified, trained liaison to serve in the SMOC Continue to: Monitor and review vaccine development, if applicable Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Promote seasonal vaccination for everyone six months of age or older, based on current



Texas Poison Control Network PHARMACY BRANCH Collaborate with other DSHS programs to maintain situational awareness of current

response activities Communicate with pharmacy associations and community or institutional pharmacies and

provide subject matter expertise and guidance, as needed Assess staffing, operations, pharmaceutical inventories, warehousing, and other capabilities

and capacities, and request additional resources, as needed Provide pre-identified, trained liaison to serve in the SMOC Continue to: Procure, receive, store, and distribute seasonal and novel influenza vaccine, if available, for

HSRs, LHDs, and private providers in coordination with the Immunization Branch Provide seasonal and novel influenza vaccine, if available, and medical supplies for DSHS

employee immunization clinics Provide oversight to regional Class D pharmacies and pharmaceutical guidance to HSRs

and LHDs ZOONOSIS CONTROL BRANCH (ZCB) Provide pre-identified, trained liaison to serve in the SMOC Continue to: Share surveillance data, in collaboration with EAIDB Regularly communicate with TAHC and other animal health partners


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ESCALATED OPERATIONS: Escalated activities are adjusted in response to complex investigations into multiple cases of novel influenza or other respiratory virus with pandemic potential. Escalated operations are handled through a limited to full activation of the operations center. CONDITIONS IN STATE Multiple confirmed, non—travel-related human cases of novel influenza or other respiratory

virus with pandemic potential within a defined geographic area in Texas Sustained transmission of novel influenza or other respiratory virus with pandemic potential

internationally Complex investigations for human cases of novel influenza or other respiratory virus with

pandemic potential High levels of public or media attention related to influenza or other respiratory virus with

pandemic potential Multiple jurisdictions with multiple Health Service Regions (HSRs) reporting emergency

response operations Reports from Texas Animal Health Commission (TAHC) of animal cases of respiratory

viruses having pandemic potential, with transmission to humans

RESPONSE ACTIVITIES

DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES HSR Director Continue to: Communicate regularly with DSHS Central Office leadership Communicate regularly with local health authorities Prepare within the jurisdiction for influenza and other viruses with pandemic potential Hold regular discussions with regional preparedness managers and staff Maintain awareness for influenza and other respiratory viruses through regular

communications with staff Ensure that leadership staff in local jurisdictions is aware of current conditions statewide Surveillance and Epidemiology Request support from DSHS Central Office, as needed Continue to: Analyze and report influenza or other respiratory virus data weekly to DSHS HSR Director,

DSHS HSR Public Health Preparedness Manager, and Emerging and Acute Infectious Disease Branch (EAIDB)

Enhance surveillance for influenza-like illness (ILI) for at least four (4) weeks or two (2) incubation periods, whichever is longer, following identification of the last case of novel influenza or other respiratory virus



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Initiate laboratory surveillance of a targeted population as directed by EAIDB Provide updates to local health departments (LHDs) and to providers in counties where the

HSR conducts surveillance and epidemiology functions Ensure guidance from the Emerging and Acute Infectious Disease Branch (EAIDB) and

Community Preparedness Section (CPS) reaches LHD staff Conduct routine surveillance and epidemiology activities in counties where the HSR office


pandemic potential immediately and notify DSHS EAIDB, as described in the Emerging and Acute Infectious Disease Investigation Guidelines


requested Immunization Hire temporary nurses and other healthcare workers to staff clinics, as needed Prepare for and conduct mass vaccination clinics, as needed, in coordination with CPS and

LHDs Communicate regularly with DSHS Immunization Branch regarding high-risk populations,

and vaccine allocation and distribution Prepare to activate the emergency module within ImmTrac in order to track antivirals,

immunizations, and medications distributed and administered during the emergency response effort

Continue to: Promote seasonal influenza vaccine for everyone six months of age or older, based on





Emergency Preparedness Determine whether current response can be handled through a limited or full activation of

the Regional Health and Medical Operations Center (RHMOC) to support the affected Disaster District Committees (DDCs)

Notify personnel of RHMOC and DDC activations and potential assignment/deployment Support Point of Dispensing (POD) sites (medication and vaccine), as needed, in

coordination with LHDs, clinicians, and pharmacies, if vaccine available Reinforce appropriate infection control behaviors for first responders, healthcare providers,

and others Monitor inventory levels of appropriate antivirals and vaccines at pharmacies and LHDs


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Prepare to activate receiving, staging, and storing (RSS) sites, if needed Distribute personal protective equipment (PPE) supplies, as needed Coordinate with local partners for projected resource needs, including the Strategic National

Stockpile (SNS) Coordinate with hospital preparedness programs to activate alternate care sites, if indicated Continue to: Provide pre-identified, trained staff to support local public health and medical response and

to serve in the RHMOC and/or DDCs Monitor Web Emergency Operations Center (WebEOC) and other emergency

communication systems Ensure federal and state guidance reaches response partners, including the regional


discussed or implemented in the HSR Communicate with other internal partners to maintain situational awareness Monitor resource reporting, including Hospital Available Beds for Emergencies and

Disasters (HAvBED) and ventilators, if not done already Develop and distribute Incident Action Plans (IAPs), Situation Reports (SitReps), and any

associated documents for each operational period, as directed by the RHMOC Director, if RHMOC activated

COMMUNITY PREPAREDNESS SECTION (CPS) Determine whether current response can be handled through a limited or full activation of

the State Medical Operations Center (SMOC) Notify all teams and personnel of SMOC activation and potential assignment or deployment Support POD sites (medication and vaccine), in coordination with HSRs, LHDs, clinicians,

and pharmacies, as needed and if vaccine available Determine an appropriate procedure to distribute medical countermeasures to pharmacies Continually assess need for additional activities, communication products, and message

dissemination Analyze all available information and coordinate with the Public Information Officer (PIO) on

appropriate news releases to media, elected officials, clinicians, or others Participate in the state Joint Information System (JIS), if activated In conjunction with 2-1-1, establish call center for general public and clinician inquiries Coordinate with the State Operations Center (SOC) and the Governor’s Office for possible

request for SNS supplies Monitor inventory levels of appropriate antivirals and vaccines at pharmacies and other sites Maintain awareness of vaccine development and share information with appropriate HSRs Monitor non-pharmaceutical intervention implementation and impact Reinforce appropriate infection control behaviors for first responders, healthcare providers,

and others Coordinate distribution of PPE supplies, as needed Coordinate with federal partners for projected resource needs, including SNS Implement non-pharmaceutical interventions for the SMOC, as appropriate Provide DSHS representative to serve in the state receiving, shipping, and storage (RSS)

sites, if activated


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Coordinate the augmentation of existing laboratory and epidemiology staff and capacity, as needed, to support response activities throughout the state

Coordinate with RHMOCs and appropriate regional healthcare coalitions to supplement hospital capacity, if needed

Activate alternate care sites, if indicated Continue to: Serve as the state primary coordinating entity for Emergency Support Function #8 (ESF-8),

Public Health and Medical Services Provide pre-identified, trained staff to serve in the SMOC Incident Command System (ICS)

structure, as needed Coordinate with appropriate HSR and RHMOC to support DDCs in affected regions Maintain event reporting in WebEOC and update Ensure appropriate state level preparedness and response documents are adhered to (e.g.,

SMOC Operations Manual, state level response operating guides and preparedness plans, Memorandums of Understanding [MOUs], contracts, private pharmacy contact lists)




Monitor resource reporting, including HAvBED and ventilators, as appropriate

CENTER FOR POLICY AND EXTERNAL AFFAIRS (CPEA) Provide pre-identified, trained PIO and government liaison to serve in the SMOC Disseminate emergency public information Conduct press conferences and conference calls to update news media Respond to high volume of inquiries from press Provide updates to legislative leadership and legislators representing affected jurisdictions Assess need for increased public education and contract with social marketing vendor to

conduct multi-media public awareness campaign, if needed Conduct outreach to hard-to-reach populations Continue to: Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Update DSHS website, including programmatic and media webpages, to include any novel

respiratory virus information, relevant precautions, and Texas case count, if applicable Promote influenza and other viral respiratory illness prevention activities Respond to requests from the media, elected officials, and the public Coordinate with other DSHS partners to establish a set schedule for releasing updated case

counts publically Distribute information to public health, medical, and emergency management partners, as


background information


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Translate emergency public information into Spanish and other languages, as appropriate Coordinate with LHD and HSR PIOs, and assess the need for JIS


EMERGING AND ACUTE INFECTIOUS DISEASES BRANCH (EAIDB) Initiate surge testing activities, in collaboration with the Laboratory Services Section Continue to: Coordinate influenza and other respiratory virus surveillance and investigations, as



(CDC) Request targeted increases in specimen submissions, in collaboration with the Laboratory


requested Review specimen submission and testing criteria and adjust if needed, in conjunction with


data weekly, or as appropriate Enhance surveillance for ILI for at least four (4) weeks or two (2) incubation periods,

whichever is longer, following identification of the last case of novel influenza or other respiratory virus



Provide pre-identified, trained liaison to serve in the SMOC

LABORATORY SERVICES SECTION Initiate surge testing activities, in collaboration with EAIDB Augment existing laboratory staff and capacity, as needed, to support response activities

throughout the state, in coordination with the SMOC Continue to: Review specimen submission and testing criteria and adjust if needed, in collaboration with


collaboration with EAIDB, referring to CDC when appropriate Maintain inventory control and order additional supplies, as needed Cross-train laboratory personnel, as needed Provide pre-identified, trained liaison to serve in the SMOC


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IMMUNIZATION BRANCH Communicate regularly with CDC regarding new influenza strains or other respiratory virus

vaccine development, manufacture, and anticipated distribution Coordinate with CDC regarding prioritization of population subgroups for new influenza

strains or other respiratory virus vaccination, depending on amounts of vaccine expected to be available and when distribution to the states could begin

Coordinate with CDC to prepare messaging to the public, providers, and others regarding new influenza strains or other respiratory virus vaccine production, efficacy, allocation, and distribution

Communicate with CDC regarding high-risk populations and possible changes in recommendations

Determine and issue recommendations for local seasonal vaccination clinics, if indicated Monitor the percentage of the population that has received seasonal vaccine, if applicable Determine when eligibility criteria for DSHS-supplied seasonal vaccine should be

suspended Implement seasonal vaccine allocation and distribution plan based on priority high-risk

populations Prepare to activate the emergency module within ImmTrac to track antivirals, immunizations,

and medications administered to individuals during the emergency response effort Continue to: Provide pre-identified, trained liaison to serve in the SMOC Collaborate with medical providers that receive vaccine from DSHS to identify their high-risk

populations and plan for potential seasonal vaccine distribution to these providers’ offices Monitor and review vaccine development, if applicable Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Promote seasonal vaccination for everyone six months of age or older, based on current



Texas Poison Control Network PHARMACY BRANCH Purchase, receive, process orders, and distribute pharmaceuticals and medical supplies, as

needed and as capacity allows Establish and operate a SNS drug repackaging site, if needed, and if resources are

available to support the effort Continue to: Provide pre-identified, trained liaison to serve in the SMOC Collaborate with other DSHS programs to maintain situational awareness of current

response activities


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Communicate with pharmacy associations and community or institutional pharmacies and provide subject matter expertise and guidance, as needed

Assess staffing, operations, pharmaceutical inventories, warehousing, and other capabilities and capacities, and request additional resources, as needed

Procure, receive, store, and distribute seasonal and novel influenza vaccine, if available, for HSRs, LHDs, and private providers, in coordination with the Immunization Branch

Provide seasonal and novel influenza vaccine, if available, and medical supplies for DSHS employee immunization clinics

Provide oversight to regional Class D pharmacies and pharmaceutical guidance to HSRs and LHDs

ZOONOSIS CONTROL BRANCH (ZCB) Continue to: Provide pre-identified, trained liaison to serve in the SMOC Share surveillance data, in collaboration with EAIDB Regularly communicate with TAHC and other animal health partners


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EMERGENCY RESPONSE OPERATIONS Emergency response activities are highly elevated and include additional activities to control a pandemic or widespread epidemic of novel influenza or other respiratory virus with pandemic potential. Emergency operations are handled through a full activation of the operations center. CONDITIONS IN STATE Multiple confirmed, non—travel-related human cases of novel influenza or other respiratory

virus with pandemic potential detected in Texas Sustained transmission of novel influenza or other respiratory virus with pandemic potential

in the U.S. Widespread human cases of novel influenza or other respiratory virus with pandemic

potential in Texas Complex investigations of human cases of novel influenza or other respiratory virus with

pandemic potential Exceptional levels of public or media attention related to influenza and other respiratory

virus with pandemic potential Multiple jurisdictions with multiple Health Service Regions (HSRs) reporting emergency

response operations Reports from Texas Animal Health Commission (TAHC) of animal cases of respiratory

viruses having pandemic potential, with transmission to humans RESPONSE ACTIVITIES

DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES HSR Director Regularly review statewide and HSR situation and consider scaling back operations, as

appropriate Support preparedness and response activities within the jurisdiction for influenza and other

viruses with pandemic potential Consider recommending implementation of Continuity of Operations Plan (COOP) activities

for the region, if necessary Continue to: Communicate regularly with DSHS Central Office leadership Communicate regularly with local health authorities Prepare within the jurisdiction for influenza and other viruses with pandemic potential Hold regular discussions with regional preparedness managers and staff Maintain awareness for influenza and other respiratory viruses through regular

communications with staff Ensure that leadership staff in local jurisdictions is aware of current conditions statewide Have regular discussions with regional preparedness managers and staff


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Surveillance and Epidemiology Modify surveillance, investigation, and reporting activities, as requested by DSHS Central

Office Continue to: Request support from DSHS Central Office, as needed Analyze and report influenza or other respiratory virus data weekly to HSR Director, HSR

Public Health Preparedness Manager, and the Emerging and Acute Infectious Disease Branch (EAIDB)

Provide updates to local health departments (LHDs) and to providers in counties where the HSR conducts surveillance and epidemiology functions

Ensure guidance from EAIDB and Community Preparedness Section (CPS) reaches LHD staff

Conduct routine surveillance and epidemiology activities in counties where the HSR office conducts these functions, as described in the Texas Influenza Surveillance Handbook



requested

Immunization Distribute DSHS guidance, based on U.S. Centers for Disease Control and Prevention

(CDC) recommendations, on prioritization of target groups for new influenza or other respiratory virus strain vaccine, if available

Recruit identified non-traditional vaccine providers Prepare to receive, store, and distribute vaccines, medications, biologicals requiring

refrigeration and/or medical supplies Activate the emergency module within ImmTrac in order to track antivirals, immunizations,

and medications distributed and administered to individuals during the emergency response effort

Conduct mass vaccination clinics, as needed, in coordination with CPS and LHDs Continue to: Hire temporary nurses and other healthcare workers to staff clinics, as needed Monitor and maintain inventory control and order additional supplies, as needed Promote seasonal influenza vaccine for everyone six months of age or older, based on






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Emergency Preparedness Fully activate the Regional Health and Medical Operations Center (RHMOC) to support the

affected Disaster District Committees (DDCs) Request state or federal resources from the State Medical Operations Center (SMOC) via

the State Operations Center (SOC), if needed Continue to: Provide pre-identified, trained staff to support local public health and medical response and

to serve in the RHMOC and/or DDCs Support Point of Dispensing (POD) sites (medication and vaccine), as needed, in

coordination with LHDs, clinicians, and pharmacies, if vaccine available Monitor Web Emergency Operations Center (WebEOC) and other emergency

communication systems Ensure federal and state guidance reaches response partners, including the regional


discussed or implemented in the HSR Communicate with other internal partners to maintain situational awareness Monitor resource reporting, including Hospital Available Beds for Emergencies and

Disasters (HAvBED) and ventilators, if not done already Develop and distribute Incident Action Plans (IAPs), Situation reports (SitReps), and any

associated documents for each operational period, as directed by the RHMOC Director, if RHMOC is activated

COMMUNITY PREPAREDNESS SECTION (CPS) Serve as the state primary coordinating entity for Emergency Support Function #8 (ESF-8),

Public Health and Medical Services Fully activate the SMOC and transition all response activities to the SMOC Scale down daily CPS activities so that response staff may work in the SMOC or SOC, as

appropriate See State Medical Operations Center, below, for more CPS emergency activities STATE MEDICAL OPERATIONS CENTER (SMOC) Incident Command and General Staff Incident command and general staff report to the SMOC, as directed by the SMOC Director Activate relevant medical materiel or staffing contracts, as needed Identify additional resources for pharmaceutical and non-pharmaceutical interventions Identify funds to support DSHS and LHD requests for resources Provide resources to HSRs and LHDs, if requested and available Request that RHMOCs regularly survey regional healthcare coalitions regarding resource

shortages Coordinate with RHMOCs and appropriate regional healthcare coalitions to supplement

hospital capacity, if needed Maintain communication with DSHS programs involved in the incident (e.g., Pharmacy

Branch, EAIDB, Laboratory Services) Coordinate with other state agencies, as appropriate Regularly review surveillance data and consider scaling back operations


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Consider recommending implementation of Continuity of Operations Plan (COOP) activities for agency

Coordinate the activation of alternate care sites and provide support, as needed Coordinate distribution of personal protective equipment (PPE) supplies, as needed If activation of Strategic National Stockpile (SNS) Plan is needed: Coordinate with Texas Department of Transportation, Texas Military Forces, Texas

Department of Public Safety, Texas Division of Emergency Management (TDEM), and other state partners to initiate SNS plan, if needed

Track, distribute, and maintain stock levels by quantity and dose of appropriate antivirals Ensure orders are prepared, pulled, and shipped according to medical countermeasures

distribution guidelines Continue to: Provide pre-identified, trained staff to serve in the SMOC Incident Command System (ICS)

structure, as needed Maintain event reporting in WebEOC and update Coordinate with appropriate RHMOC to support DDCs in affected regions Develop and distribute IAPs, SitReps, Dashboards, and any associated documents for each

operational period, as directed by the SMOC Director Support POD sites (medication and vaccine), as needed, in coordination with HSRs, LHDs,

clinicians, and pharmacies, if vaccine available Determine an appropriate procedure to distribute medical countermeasures to pharmacies Coordinate with partners to create status and update reports for DSHS leadership, as

needed Maintain SMOC conference call schedules to keep appropriate public health and medical

partners informed (e.g., HSRs, LHDs, RHMOCs, Emergency Operation Centers [EOCs], Regional Advisory Councils [RACs])

Monitor non-pharmaceutical intervention implementation and impact Implement non-pharmaceutical interventions for SMOC and RHMOCs, as appropriate Reinforce appropriate infection control behaviors for first responders, healthcare providers,

and others Continue to monitor resource reporting, including ventilators as well as HAvBED Coordinate the augmentation of existing laboratory and epidemiology staff and capacity, as

needed, to support response activities throughout the state Inform and coordinate with federal partners for projected resource needs, including SNS Analyze all available information and coordinate with the Public Information Officer (PIO) on

appropriate news releases to media, elected officials, clinicians, or others Participate in the state Joint Information System (JIS), if activated Provide DSHS representative to serve in the state receiving, staging, and storing (RSS)

sites, if activated


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Provide pre-identified, trained PIO and government liaison to serve in the SMOC, if requested

Assess need for additional activities, communication products, and messages Issue statements and/or news releases on recommendations and major developments Operate in the state JIS, if indicated Transition to full scale legislative communications, providing regular, proactive updates to

legislators and consider briefings at the Capitol as appropriate, based on level of interest and concern

Coordinate with LHD and HSR PIOs to ensure consistent messages, as necessary Consider scaling operations, as appropriate Continue to: Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Update DSHS website, including programmatic and media webpages, to include any novel

respiratory virus information, relevant precautions, and Texas case count, if applicable Promote influenza and other viral respiratory illness prevention activities Respond to requests from the media, from elected officials, and the public Coordinate with other DSHS partners to establish a set schedule for releasing updated case



background information Translate emergency public information into Spanish and other languages, as appropriate Coordinate with LHD and HSR PIOs, and assess the need for a JIS Provide updates to legislative leadership and legislators representing affected jurisdictions Disseminate emergency public information Conduct press conferences and conference calls to update news media Respond to high volume of inquiries from press, legislators, leadership of affected

communities, and other elected officials and address any misinformation Assess need for increased public education and contract with social marketing vendor to

conduct multi-media public awareness campaign, if needed Conduct outreach to hard-to-reach populations DIVISION FOR DISEASE CONTROL AND PREVENTION SERVICES

EMERGING AND ACUTE INFECTIOUS DISEASES BRANCH (EAIDB) Revise case criteria and outbreak definitions, in conjunction with the Epidemiology Advisory

Group (EAG) Conduct seasonal influenza surveillance and epidemiologic investigations of highest priority

influenza or other respiratory virus with pandemic potential reports Regularly review surveillance data and activities and consider scaling back operations Continue to: Coordinate influenza and other respiratory virus surveillance and investigations, as

described in the Texas Influenza Surveillance Handbook


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Monitor and maintain National Electronic Disease Surveillance System (NEDSS) Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to HSR and LHD staff on investigations of novel




the Laboratory Services Section and the EAG Analyze and report seasonal, novel and/or pandemic influenza or other respiratory virus

data weekly, or as appropriate Enhance surveillance for influenza-like illness (ILI) for at least four (4) weeks or two (2)

incubation periods, whichever is longer, following identification of the last case of novel influenza or other respiratory virus



Monitor surge testing activities and adjust accordingly, in collaboration with the Laboratory Services Section

Provide pre-identified, trained liaison to serve in the SMOC LABORATORY SERVICES SECTION Regularly review surveillance data, in collaboration with EAIDB, and consider scaling back

operations Continue to: Monitor surge testing activities and adjust accordingly, in collaboration with EAIDB and the

EAG Review specimen submission and testing criteria and adjust if needed, in collaboration with


collaboration with EAIDB, referring to CDC when appropriate Maintain inventory control and order additional supplies, as needed Cross-train laboratory personnel, as needed Provide pre-identified, trained liaison to serve in the SMOC Augment existing laboratory staff and capacity, as needed, to support response activities

throughout the state, in coordination with the SMOC


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IMMUNIZATION BRANCH Suspend eligibility criteria for DSHS-supplied seasonal vaccine, if appropriate Provide DSHS-supplied seasonal vaccine to priority high-risk populations and then to the

general public, if appropriate Support mass vaccination clinics, if applicable Activate the emergency module within ImmTrac to track antivirals, immunizations, and

medications administered to individuals during the emergency response effort Regularly review surveillance data and consider scaling back operations Continue to: Provide pre-identified, trained liaison to serve in the SMOC Communicate regularly with CDC regarding new influenza strains or other respiratory virus




Communicate with CDC regarding high-risk populations regarding possible changes in recommendations

Monitor the percentage of the population that has received seasonal vaccine, if applicable Collaborate with medical providers that receive vaccine from DSHS to identify their high-risk

populations and plan for potential seasonal vaccine distribution to these providers’ offices Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Promote seasonal vaccination for everyone six months of age or older, based on current



Texas Poison Control Network PHARMACY BRANCH Regularly review surveillance data, in collaboration with EAIDB, and consider scaling back

operations Continue to: Provide pre-identified, trained liaison to serve in the SMOC Collaborate with other DSHS programs to maintain situational awareness of current



and capacities, and request additional resources, as needed


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Procure, receive, store, and distribute seasonal and novel influenza vaccine, if available, for HSRs, LHDs, and private providers in coordination with the Immunization Branch



Purchase, receive, process orders, and distribute pharmaceuticals and medical supplies, as needed and as capacity allows

Operate a SNS drug repackaging site, if needed, and if resources are available to support the effort

ZOONOSIS CONTROL BRANCH (ZCB) Provide pre-identified, trained liaison to serve in the SMOC and/or EAG Regularly review surveillance data and consider scaling back operations, if indicated Continue to: Share surveillance data, in collaboration with EAIDB Regularly communicate with TAHC and other animal health partners EPIDEMIOLOGY ADVISORY GROUP (EAG) (Composed of DSHS laboratory, epidemiology, and medical expert representatives) Provide epidemiology and surveillance data to SMOC staff and DSHS leadership Provide fact sheets for the public for distribution through CPEA Provide consultation to SMOC and DSHS leadership Refine the outbreak case definition, when indicated Analyze and interpret data on Texas cases Make recommendations on control measures, based on available data Regularly review surveillance data and consider scaling back operations


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VI. ACRONYMS

Acronym Spelled out

CPEA Center for Policy and External Affairs (DSHS) CDC U.S. Centers for Disease Control and Prevention CHIP Children’s Health Insurance Program (Children’s Medicaid) CPS Community Preparedness Section (DSHS) DCPS Disease Control and Prevention Services (DSHS) DDC Disaster District Committee (Texas) DSHS Department of State Health Services (Texas) EAG Epidemiology Advisory Group (DSHS) EAIDB Emerging and Acute Infectious Disease Branch (DSHS) EOC Emergency Operations Center ESF-8 Emergency Support Function #8 HAvBED Hospital Available Beds for Emergencies and Disasters HHSC Health and Human Services Commission HSR Health Service Region (DSHS) ICS Incident Command System IISP Influenza Incidence Surveillance Project ILI influenza-like illness ILINet Influenza-Like Illness Surveillance Network JIS Joint Information System LHD local health department LRN Laboratory Response Network MERS-CoV Middle Eastern Respiratory Syndrome, a coronavirus MOU Memorandum of Understanding NEDSS National Electronic Disease Surveillance System PHIN Public Health Information Network PIO Public Information Officer POD Point of Dispensing PPE personal protective equipment RAC Regional Advisory Council (DSHS) RHMOC Regional Health and Medical Operations Center RPD respiratory protective device SME subject matter expert SMOC State Medical Operations Center (DSHS) SNS Strategic National Stockpile TAHC Texas Animal Health Commission TDEM Texas Division of Emergency Management TPCN Texas Poison Control Network TVFC Texas Vaccines for Children VAAC Vaccine Allocation Advisory Committee VAERS Vaccine Adverse Event Reporting System WebEOC Web Emergency Operations Center WHO World Health Organization ZCB Zoonosis Control Branch (DSHS)


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VII. REFERENCES Texas Influenza Surveillance Handbook www.dshs.state.tx.us/idcu/disease/influenza/Texas-Influenza-Surveillance-Handbook/ Guidelines for Investigation and Control of Invasive, Respiratory and Vaccine Preventable Diseases http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589974579 Federal Emergency Management Agency – Emergency Support Function #8 (ESF-8) http://www.fema.gov/media-library-data/20130726-1825-25045-8027/emergency_support_function_8_public_health___medical_services_annex_2008.pdf


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VIII. RECORD OF CHANGES This section describes changes made to this document: when they were made, what they were, and who authorized them. Use this table to record: Change number, in sequence, beginning with 1 Date change was made to the document Description of change and rationale, if applicable Name of person who made the change

Change number

Date of change Description

Change made by (PRINT NAME)


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IX. CONTRIBUTORS This section provides a list of individuals who contributed to the development of this document. Besides the individuals below, significant contributions were provided by local health department directors and Health Service Region Directors and staff. State Epidemiologist L. Gaul

Center for Policy and Consumer Affairs W. Ayres

R. Garcia R. Hendrickson J. Villarreal

Division for Disease Control and Prevention Services Emerging and Acute Infectious Disease Branch

L. Brannan L. Cornelius M. Felkner

Immunization Branch

M. Gamez S. Rai L. Valenzuela B. Vassell

Laboratory Services Section G. Kubin

Pharmacy Branch K. Condon C. Handy

Zoonosis Control Branch T. Sidwa

Division of Regional and Local Health Services Community Preparedness Section

B. Adams P. Boston B. Clements M. Czepiel B. Damis D. Hesse J. Hoogheem M. McElwain L. Osborne K. Sanches M. Simanek

Health Service Region 4/5N P. McGaha

Health Service Region 7 C. Davis


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X. SUPPLEMENTS DSHS PROGRAMMATIC RESPONSE ACTIVITIES The following pages contain activities to be conducted by the different programs involved in a respiratory virus pandemic response within the Department of State Health Services. The programs included are outlined below by page number. DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) pg. S-1 – S-13 HEALTH SERVICE REGION OFFICES

Regional Director……………………………………………………………………….. pg. S-1 Surveillance and Epidemiology ……………………………………………………….. pg. S-3 Immunization ……………………………………………………………………………. pg. S-5 Emergency Preparedness …………………………………………………………...... pg. S-7

COMMUNITY PREPAREDNESS SECTION ……….………………………………………. pg. S-10 State Medical Operations Center………….…………………………………………. pg. S-13

CENTER FOR POLICY AND EXTERNAL AFFAIRS (CPEA) pg. S-15 – S-17 DIVISION FOR DISEASE CONTROL AND PREVENTION SERVICES (DCPS) pg. S-18 – S-29

Emerging and Acute Infectious Disease Branch……………….………….. ……….pg. S-18 Laboratory Services Section ………………………………………………… ……….pg. S-21 Immunization Branch ………………………………………………………… ……….pg. S-23 Pharmacy Branch ……………………………………………………………………... pg. S-26 Zoonosis Control Branch ………………………………………………………………pg. S-28 Epidemiology Advisory Group………….………………………………………………pg. S-29


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DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES HSR Director

ROUTINE OPERATIONS Maintain awareness for influenza and other respiratory viruses through regular


with pandemic potential

ENHANCED OPERATIONS Continue to: Maintain awareness for influenza and other respiratory viruses through regular


with pandemic potential

INCREASED READINESS OPERATIONS Communicate regularly with DSHS Central Office leadership Communicate regularly with local health authorities Prepare within the jurisdiction for influenza and other viruses with pandemic potential Hold regular discussions with regional preparedness managers and staff Continue to: Maintain awareness for influenza and other respiratory viruses through regular

communications with staff Ensure that leadership staff in local jurisdictions is aware of current conditions statewide

ESCALATED OPERATIONS

Continue to: Communicate regularly with DSHS Central Office leadership Communicate regularly with local health authorities Prepare within the jurisdiction for influenza and other viruses with pandemic potential Hold regular discussions with regional preparedness managers and staff Maintain awareness for influenza and other respiratory viruses through regular

communications with staff Ensure that leadership staff in local jurisdictions is aware of current conditions statewide

EMERGENCY RESPONSE OPERATIONS Regularly review statewide and HSR situation and consider scaling back operations Support preparedness and response activities within the jurisdiction for influenza and other

viruses with pandemic potential Consider recommending implementation of Continuity of Operations Plan (COOP) activities

for the region Continue to: Communicate regularly with DSHS Central Office leadership Communicate regularly with local health authorities Prepare within the jurisdiction for influenza and other viruses with pandemic potential


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Hold regular discussions with regional preparedness managers and staff Maintain awareness for influenza and other respiratory viruses through regular

communications with staff Ensure that leadership staff in local jurisdictions is aware of current conditions statewide Communicate regularly with regional preparedness managers and staff


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DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS)

HEALTH SERVICE REGION (HSR) OFFICES Surveillance and Epidemiology

ROUTINE OPERATIONS Conduct routine surveillance and epidemiology activities in counties where the Health

Service Region (HSR) office conducts these functions, as described in the Texas Influenza Surveillance Handbook


Provide subject matter expertise, guidance, and support to local health department (LHD) staff, as needed

Coordinate influenza surveillance and reporting activities across all counties in the HSR

ENHANCED OPERATIONS Provide updates to LHD and to providers in counties where the HSR conducts surveillance

and epidemiology functions Ensure guidance from the Emerging and Acute Infectious Disease Branch (EAIDB) and the

Community Preparedness Section (CPS) reaches LHD staff Enhance surveillance for influenza-like illness (ILI) for at least four (4) weeks or two (2)

incubation periods, whichever is longer, following identification of novel influenza or other respiratory virus by actively following up with routine reporters to ensure timely reports

Assist jurisdictions with case investigations, data entry, and other surge capacity, as requested

Continue to: Conduct routine surveillance and epidemiology activities in counties where the HSR office



Provide subject matter expertise, guidance, and support to LHD staff, as needed Coordinate influenza surveillance and reporting activities across all counties in the HSR

INCREASED READINESS OPERATIONS Analyze and report influenza or other respiratory virus data weekly to DSHS HSR Director,

DSHS HSR Public Health Preparedness Manager, and EAIDB Enhance surveillance for ILI for at least four (4) weeks or two (2) incubation periods,



Initiate laboratory surveillance of a targeted population as directed by EAIDB Continue to: Provide updates to LHDs and to providers in counties where the HSR conducts surveillance

and epidemiology functions Ensure guidance from EAIDB and the CPS reaches LHD staff Conduct routine surveillance and epidemiology activities in counties where the HSR office

conducts these functions, as described in the Texas Influenza Surveillance Handbook


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requested

ESCALATED OPERATIONS Request support from DSHS Central Office, as needed Continue to: Analyze and report influenza or other respiratory virus data weekly to DSHS HSR Director,

DSHS HSR Public Health Preparedness Manager, and EAIDB Enhance surveillance for ILI for at least four (4) weeks or two (2) incubation periods,



Initiate laboratory surveillance of a targeted population as directed by EAIDB Provide updates to LHD and to providers in counties where the HSR conducts surveillance

and epidemiology functions Ensure guidance from the EAIDB and CPS reaches LHD staff Conduct routine surveillance and epidemiology activities in counties where the HSR office


pandemic potential immediately and notify DSHS EAIDB, as described in the Emerging and Acute Infectious Disease Investigation Guidelines


requested

EMERGENCY RESPONSE OPERATIONS Modify surveillance, investigation, and reporting activities, as requested by DSHS Central

Office Continue to: Request support from DSHS Central Office, as needed Analyze and report influenza or other respiratory virus data weekly to HSR Director, HSR

Public Health Preparedness Manager, and the EAIDB Provide updates to LHD and to providers in counties where the HSR conducts surveillance

and epidemiology functions Ensure guidance from EAIDB and CPS reaches LHD staff Conduct routine surveillance and epidemiology activities in counties where the HSR office




requested


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DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES Immunization

ROUTINE OPERATIONS Promote seasonal influenza vaccine for everyone six months of age or older, based on




orders, and providing technical assistance to public health clinics, local health departments (LHDs), and TVFC provider offices

ENHANCED OPERATIONS





INCREASED READINESS OPERATIONS

Coordinate with local jurisdictions in preparation for mass vaccination clinics, in coordination with Community Preparedness Section (CPS)

Distribute DSHS guidance, based on U.S. Centers for Disease Control and Prevention (CDC) recommendations, on prioritization of target groups for new influenza or other respiratory virus strain vaccine, if available

Coordinate strategic discussions about vaccine allocations Distribute information from DSHS Immunization Branch to TVFC providers and LHDs

regarding high-risk populations, and vaccine allocation and distribution Monitor and maintain inventory control and order additional supplies, as needed Develop a plan with other HSR staff to identify and recruit non-traditional vaccine providers Review plans with other HSR staff to receive, store, and distribute vaccines, medications,

biologics requiring refrigeration and/or medical supplies Activate plans for distribution of any available pre-pandemic vaccine Continue to: Promote seasonal influenza vaccine for everyone six months of age or older, based on


clinic sites


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Vaccinate HSR staff Vaccinate qualifying TVFC and adult clients served by local public health clinic sites Recruit providers to TVFC Program and ImmTrac Manage immunization operations by monitoring vaccine inventory, approving vaccine



Hire temporary nurses and other healthcare workers to staff clinics, as needed Prepare for and conduct mass vaccination clinics, as needed, in coordination with CPS and

LHDs Communicate regularly with DSHS Immunization Branch regarding high-risk populations,

and vaccine allocation and distribution Prepare to activate the emergency module within ImmTrac in order to track antivirals,

immunizations, and medications distributed and administered during the emergency response effort





EMERGENCY RESPONSE OPERATIONS

Distribute DSHS guidance, based on CDC recommendations, on prioritization of target groups for new influenza or other respiratory virus strain vaccine, if available

Recruit identified non-traditional vaccine providers Prepare to receive, store, and distribute vaccines, medications, biologicals requiring

refrigeration and/or medical supplies Activate the emergency module within ImmTrac in order to track antivirals, immunizations,

and medications distributed and administered to individuals during the emergency response effort

Conduct mass vaccination clinics, as needed, in coordination with CPS and LHDs Continue to: Hire temporary nurses and other healthcare workers to staff clinics, as needed Monitor and maintain inventory control and order additional supplies, as needed Promote seasonal influenza vaccine for everyone six months of age or older, based on





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DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) HEALTH SERVICE REGION (HSR) OFFICES Emergency Preparedness

ROUTINE OPERATIONS Serve as the coordinating entity for Emergency Support Function #8 (ESF-8), Public Health

and Medical Services to support the Disaster District Committees (DDCs) within the Health Service Region (HSR)

Identify and train staff to support local public health and medical response and to serve in the DDCs and/or Regional Health and Medical Operations Center (RHMOC)

Maintain and update RHMOC operating procedures Maintain regional tactical communications equipment Maintain cache of antivirals, if appropriate Maintain regional Strategic National Stockpile (SNS) and other appropriate plans Maintain routine communication with the Laboratory Response Network (LRN) Maintain routine communication with local health departments (LHDs), Texas Division of

Emergency Management (TDEM), and appropriate local emergency management

ENHANCED OPERATIONS Determine whether current response can be handled at a programmatic level or through a

virtual activation of the RHMOC to support the affected DDCs Assign pre-identified, trained staff to support local public health and medical response and

to serve in the RHMOC and/or DDCs Develop and distribute Incident Action Plans (IAPs), Situation Reports (SitReps), and any

associated documents for each operational period, as directed by the RHMOC Director, if RHMOC is activated

Ensure federal and state guidance reaches response partners, including the regional healthcare coalitions and local emergency management

Provide DSHS Central Office with information on non-pharmaceutical interventions being discussed or implemented in the HSR

Communicate with other internal partners to maintain situational awareness Encourage hospitals and congregate care settings to review and update their prevention

and control procedures Continue to: Serve as the coordinating entity for Emergency Support Function #8 (ESF-8), Public Health

and Medical Services for the DDCs within the HSR Maintain routine communication with LHDs, TDEM personnel and appropriate local

emergency management

INCREASED READINESS OPERATIONS Determine whether current response can be handled through a virtual or limited activation of

the RHMOC to support the affected DDCs Provide pre-identified, trained staff to support local public health and medical response and

to serve in the RHMOC and/or DDCs Monitor Web Emergency Operations Center (WebEOC) and other emergency

communication systems Activate resource reporting, including Hospital Available Beds for Emergencies and

Disasters (HAvBED) and ventilators, if not done already


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Work with Immunizations to activate plans for distribution of any available pre-pandemic vaccine

Identify and verify location and operability of receiving, staging, and storage sites for federal antiviral distribution

Coordinate the preparation for and the support of Point of Dispensing (POD) sites (medication and vaccine), as needed, in coordination with LHDs, clinicians, and pharmacies, if vaccine available

Continue to: Ensure federal and state guidance reaches response partners, including the regional


discussed or implemented in the HSR Communicate with other internal partners to maintain situational awareness Develop and distribute IAPs, SitReps, and any associated documents for each operational

period, as directed by the RHMOC Director, if RHMOC activated

ESCALATED OPERATIONS Determine whether current response can be handled through a limited or full activation of

the RHMOC to support the affected DDCs Notify personnel of RHMOC and DDC activations and potential assignment/deployment Support Point of Dispensing (POD) sites (medication and vaccine), as needed, in

coordination with LHDs, clinicians, and pharmacies, if vaccine available Reinforce appropriate infection control behaviors for first responders, healthcare providers,

and others Monitor inventory levels of appropriate antivirals and vaccines at pharmacies and LHDs Prepare to activate receiving, staging, and storing (RSS) sites, if needed Distribute personal protective equipment (PPE) supplies, as needed Coordinate with local partners for projected resource needs, including the Strategic National

Stockpile (SNS) Coordinate with hospital preparedness programs to activate alternate care sites, if indicated Continue to: Provide pre-identified, trained staff to support local public health and medical response and

to serve in the RHMOC and/or DDCs Monitor WebEOC and other emergency communication systems Ensure federal and state guidance reaches response partners, including the regional


discussed or implemented in the HSR Communicate with other internal partners to maintain situational awareness Monitor resource reporting, including HAvBED and ventilators, if not done already Develop and distribute IAPs, SitReps, and any associated documents for each operational


EMERGENCY RESPONSE OPERATIONS Fully activate the RHMOC to support the affected DDCs Request state or federal resources from the State Medical Operations Center (SMOC) via

the State Operations Center (SOC), if needed Continue to: Provide pre-identified, trained staff to support local public health and medical response and

to serve in the RHMOC and/or DDCs


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Support POD sites (medication and vaccine), as needed, in coordination with LHDs, clinicians, and pharmacies, if vaccine available

Monitor WebEOC and other emergency communication systems Ensure federal and state guidance reaches response partners, including the regional


discussed or implemented in the HSR Communicate with other internal partners to maintain situational awareness Monitor resource reporting, including HAvBED and ventilators, if not done already Develop and distribute IAPs, SitReps, and any associated documents for each operational



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DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) COMMUNITY PREPAREDNESS SECTION (CPS)

ROUTINE OPERATIONS Serve as the primary state coordinating agency for Emergency Support Function #8 (ESF-

8), Public Health and Medical Services Identify and train staff to serve in the State Medical Operations Center (SMOC) Incident

Command System (ICS) structure Maintain and update state level preparedness and response documents (e.g., SMOC


Maintain SMOC tactical communications equipment and communications platforms (Public Health Information Network [PHIN], Emergency Management Resource, Web Emergency Operations Center [WebEOC])

Plan for the procurement, storage, and distribution of state controlled caches of antiviral medications, (non-seasonal) influenza vaccines, and other medical assets for pandemic response

Maintain routine communication with DSHS Health Service Region (HSR) Directors, Regional Preparedness Program Managers, and Texas Division of Emergency Management (TDEM) preparedness staff

ENHANCED OPERATIONS

Determine if the current response can be managed effectively without a full activation of the SMOC; alternatives include managing operations at the programmatic level or through a virtual activation of the SMOC

Assess the possible need for distribution of antiviral medications, influenza vaccine, personal protective equipment (PPE), and other medical assets for pandemic response, in coordination with appropriate DSHS subject matter experts (SMEs)

Consider activating healthcare resource reporting, including Hospital Available Beds for Emergencies and Disasters (HAvBED) and ventilators

Discuss and/or assess non-pharmaceutical intervention implementation Establish regular communication with private vendors and community pharmacies and other

private sector partners that provide medical resources Coordinate a review of roles and responsibilities with all participating DSHS partners and

stakeholders If the SMOC is activated: Assign and provide pre-identified, trained staff to the SMOC ICS structure Coordinate with appropriate HSRs to activate the RHMOC in support of the DDCs in

affected regions, as needed Establish event reporting in WebEOC and update Operationalize appropriate state level preparedness and response documents (e.g., SMOC

Operations Manual, state level response operating guides and preparedness plans, MOUs, contracts, private pharmacy contact lists)



Coordinate with partners to create status and update reports for DSHS leadership, as


S-11 | P a g e

needed Continue to: Serve as the primary state coordinating agency for Emergency Support Function #8 (ESF-

8), Public Health and Medical Services Maintain routine communication with DSHS HSR Directors, Regional Preparedness

Program Managers and TDEM preparedness staff

INCREASED READINESS OPERATIONS Determine whether current response can be handled through a virtual or limited activation of

the SMOC Provide pre-identified, trained staff to the SMOC ICS structure Coordinate with appropriate HSR to activate RHMOC in support of DDCs in affected regions Establish event reporting in WebEOC and update Ensure adherence to appropriate state level preparedness and response documents (e.g.,

SMOC Operations Manual, state level response operating guides and preparedness plans, MOUs, contracts, private pharmacy contact lists)


Establish and maintain SMOC conference call schedules to keep appropriate public health and medical partners informed (e.g., HSRs, LHDs, RHMOCs, EOCs, RACs)


Activate resource reporting, including HAvBED and ventilators Recommend implementation of non-pharmaceutical interventions Identify additional sources of antiviral medications, influenza vaccine, PPE, and other

medical assets for pandemic response, in coordination with appropriate DSHS SMEs In consult with DSHS Executive Leadership, prepare to activate plans for allocation and

distribution of any available vaccine and/or antiviral medications Identify and verify location and operability of receiving, staging, and storing (RSS) sites for federal antiviral distribution

Provide decision making recommendations for healthcare allocation of scarce resources Coordinate the preparation and support of POD sites (medication and vaccine), as needed,

in coordination with HSRs, LHDs, clinicians, and pharmacies Disseminate PPE guidance for responders and clinicians, in coordination with appropriate

SMEs Collect information from participating DSHS partners and stakeholders to identify the critical

support elements and expectations Request regular epidemiology updates from the Emerging and Acute Infectious Disease

Branch (EAIDB) Coordinate regularly with the Center for Policy and External Affairs (CPEA) to ensure

consistent public messaging Continue to: Serve as the primary state coordinating agency for Emergency Support Function #8 (ESF-

8), Public Health and Medical Services Maintain regular communication with private vendors and community pharmacies and other

private sector partners that provide medical resources

ESCALATED OPERATIONS Determine whether current response can be handled through a limited or full activation of

the SMOC Notify all teams and personnel of SMOC activation and potential assignment/deployment


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Support POD sites (medication and vaccine), in coordination with HSRs, LHDs, clinicians, and pharmacies, as needed and if vaccine available

Determine an appropriate procedure to distribute medical countermeasures to pharmacies Continually assess need for additional activities, communication products, and message

dissemination Analyze all available information and coordinate with the Public Information Officer (PIO) on

appropriate news releases to media, elected officials, clinicians, or others Participate in the state Joint Information System (JIS), if activated In conjunction with 2-1-1, establish call center for general public and clinician inquiries Coordinate with the State Operations Center (SOC) and the Governor’s Office for possible

request for SNS supplies Monitor inventory levels of appropriate antivirals and vaccines at pharmacies and other sites Maintain awareness of vaccine development and share information with appropriate HSRs Monitor non-pharmaceutical intervention implementation and impact Reinforce appropriate infection control behaviors for first responders, healthcare providers,

and others Coordinate distribution of PPE supplies, as needed Coordinate with federal partners for projected resource needs, including SNS Implement non-pharmaceutical interventions for SMOC, as appropriate Provide DSHS representative to serve in the state RSS sites, if activated Coordinate the augmentation of existing laboratory and epidemiology staff and capacity, as

needed, to support response activities throughout the state Coordinate with RHMOCs and appropriate regional healthcare coalitions to supplement

hospital capacity, if needed Activate alternate care sites, if indicated Continue to: Serve as the state primary coordinating entity for Emergency Support Function #8 (ESF-8),

Public Health and Medical Services Provide pre-identified, trained staff to serve in the SMOC ICS structure, as needed Coordinate with appropriate HSR and RHMOC to support DDCs in affected regions Maintain event reporting in WebEOC and update Ensure appropriate state level preparedness and response documents are adhered to (e.g.,

SMOC Operations Manual, state level response operating guides and preparedness plans, MOUs, contracts, private pharmacy contact lists)



Establish and maintain SMOC conference call schedules to keep appropriate public health and medical partners informed (e.g., HSRs, LHDs, RHMOCs, EOCs, RACs)

Monitor resource reporting, including HAvBED and ventilators, as appropriate

EMERGENCY RESPONSE OPERATIONS Serve as the state primary coordinating entity for Emergency Support Function #8 (ESF-8),

Public Health and Medical Services Fully activate the SMOC and transition all response activities to the SMOC Scale down daily CPS activities so that response staff may work in the SMOC or SOC, as

appropriate See State Medical Operations Center, below, for more CPS emergency activities


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DIVISION FOR REGIONAL AND LOCAL HEALTH SERVICES (RLHS) STATE MEDICAL OPERATIONS CENTER (SMOC)

EMERGENCY RESPONSE OPERATIONS Incident Command and General Staff Incident command and general staff report to the SMOC, as directed by the SMOC Director Activate relevant medical materiel or staffing contracts, as needed Identify additional resources for pharmaceutical and non-pharmaceutical interventions Identify funds to support DSHS and local health department (LHD) requests for resources Provide resources to Health Service regions (HSRs) and LHDs, if requested and available Request that Regional Health and Medical Operations Centers (RHMOCs) regularly survey

regional healthcare coalitions regarding resource shortages Coordinate with RHMOCs and appropriate regional healthcare coalitions to supplement

hospital capacity, if needed Maintain communication with DSHS programs involved in the incident (e.g., Pharmacy

Branch, Emerging and Acute Infectious Disease Branch [EAIDB], Laboratory Services) Coordinate with other state agencies as appropriate Regularly review surveillance data and consider scaling back operations Consider recommending implementation of Continuity of Operations Plan (COOP) activities

for agency Coordinate the activation of alternate care sites and provide support, as needed Coordinate distribution of personal protective equipment (PPE) supplies, as needed If activation of Strategic National Stockpile (SNS) Plan is needed: Coordinate with Texas Department of Transportation, Texas Military Forces, Texas

Department of Public Safety, Texas Division of Emergency Management (TDEM), and other state partners to initiate SNS plan, if needed

Track, distribute, and maintain stock levels by quantity and dose of appropriate antivirals Ensure orders are prepared, pulled, and shipped according to medical countermeasures

distribution guidelines Continue to: Provide pre-identified, trained staff to serve in the SMOC Incident Command System (ICS)

structure, as needed Maintain event reporting in WebEOC and update Coordinate with appropriate RHMOC to support DDCs in affected regions Develop and distribute Incident Action Plans (IAPs), Situation Reports (SitReps),

Dashboards, and any associated documents for each operational period, as directed by the SMOC Director

Support POD sites (medication and vaccine), as needed, in coordination with HSRs, LHDs, clinicians, and pharmacies, if vaccine available

Determine an appropriate procedure to distribute medical countermeasures to pharmacies Coordinate with partners to create status and update reports for DSHS leadership, as

needed Maintain SMOC conference call schedules to keep appropriate public health and medical

partners informed (e.g., HSRs, LHDs, RHMOCs, Emergency Operation Centers [EOCs], Regional Advisory Councils [RACs])

Monitor non-pharmaceutical intervention implementation and impact Implement non-pharmaceutical interventions for SMOC and RHMOCs, as appropriate


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Reinforce appropriate infection control behaviors for first responders, healthcare providers, and others

Continue to monitor resource reporting, including ventilators as well as Hospital Available Beds for Emergencies and Disasters (HAvBED)

Coordinate the augmentation of existing laboratory and epidemiology staff and capacity, as needed, to support response activities throughout the state

Inform and coordinate with federal partners for projected resource needs, including SNS Analyze all available information and coordinate with the Public Information Officer (PIO) on

appropriate news releases to media, elected officials, clinicians, or others Participate in the state Joint Information System (JIS), if activated Provide DSHS representative to serve in the state receiving, staging, and storing (RSS)

sites, if activated


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ROUTINE OPERATIONS Respond to respiratory virus and influenza-like illness (ILI)related media calls, legislative

requests, and questions from the public Monitor news media Update DSHS website, including programmatic and media webpages, to include any novel

respiratory virus information and relevant precautions, as appropriate Promote influenza and other viral respiratory illness prevention activities Identify and train public information officer (PIO) and government liaison to serve in the

State Medical Operations Center (SMOC) during an activation

ENHANCED OPERATIONS Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Initiate coordination with local health department (LHD) and Health Service Region (HSR)

PIOs Assign pre-identified, trained PIO and government liaison to serve in the SMOC Continue to: Respond to respiratory virus and ILI-related media calls, legislative requests, and questions

from the public Monitor news media Update DSHS website, including programmatic and media webpages, to include any novel


INCREASED READINESS OPERATIONS Provide pre-identified, trained PIO and government liaison to serve in the SMOC, if

requested Consult with DSHS leadership and subject matter experts (SMEs) to assess need for

emergency public information dissemination Respond to increases in press, legislative, and LHD inquiries and address any

misinformation Respond to requests from the media, elected officials, and the public Determine size and scope of public awareness campaign, if needed Coordinate with other DSHS partners to establish a set schedule for releasing updated

Texas case counts publically Distribute information to public health, medical, and emergency management partners, as


background information Translate emergency public information into Spanish and other languages, as appropriate Coordinate with LHD and HSR PIOs, and assess the need for Joint Information System

(JIS) Continue to: Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Update DSHS website, including programmatic and media webpages, to include any novel



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Provide pre-identified, trained PIO and government liaison to serve in the SMOC, if requested

Disseminate emergency public information Conduct press conferences and conference calls to update news media Respond to high volume of inquiries from press Provide updates to legislative leadership and legislators representing affected jurisdictions Assess need for increased public education and contract with social marketing vendor to

conduct multimedia public awareness campaign, if needed Conduct outreach to hard-to-reach populations Continue to: Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Update DSHS website, including programmatic and media webpages, to include any novel

respiratory virus information, relevant precautions, and Texas case count, if applicable Promote influenza and other viral respiratory illness prevention activities Respond to requests from the media, elected officials, and the public Coordinate with other DSHS partners to establish a set schedule for releasing updated case



background information Translate emergency public information into Spanish and other languages, as appropriate Coordinate with LHD and HSR PIOs, and assess the need for JIS

EMERGENCY RESPONSE OPERATIONS Provide pre-identified, trained PIO and government liaison to serve in the SMOC, if

requested Assess need for additional activities, communication products, and messages Issue statements and/or news releases on recommendations and major developments Operate in the state JIS, if indicated Transition to full scale legislative communications, providing regular, proactive updates to

legislators and consider briefings at the Capitol as appropriate, based on level of interest and concern

Coordinate with LHD and HSR PIOs to ensure consistent messages, as necessary Consider scaling back operations Continue to: Assess the public’s need for information and issue public information, as indicated Engage social media, as indicated Update DSHS website, including programmatic and media webpages, to include any novel

respiratory virus information, relevant precautions, and Texas case count, if applicable Promote influenza and other viral respiratory illness prevention activities Respond to requests from the media, from elected officials, and the public Coordinate with other DSHS partners to establish a set schedule for releasing updated case



background information


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Translate emergency public information into Spanish and other languages, as appropriate Coordinate with LHD and HSR PIOs, and assess the need for JIS Provide updates to legislative leadership and legislators representing affected jurisdictions Disseminate emergency public information Conduct press conferences and conference calls to update news media Respond to high volume of inquiries from press, legislators, leadership of affected

communities, and other elected officials and address any misinformation Assess need for increased public education and contract with social marketing vendor to

conduct multi-media public awareness campaign, if needed Conduct outreach to hard-to-reach populations


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EMERGING AND ACUTE INFECTIOUS DISEASES BRANCH (EAIDB)

ROUTINE OPERATIONS Coordinate influenza and other respiratory virus surveillance and investigations, as

described in the Texas Influenza Surveillance Handbook Monitor and maintain the National Electronic Disease Surveillance System (NEDSS) Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to Health Service Region (HSR) and local health

department (LHD) staff on investigations of novel influenza or other respiratory viruses with pandemic potential

Maintain regular communication with U.S. Centers for Disease Control and Prevention (CDC)

Identify and train liaison to serve in the State Medical Operations Center (SMOC) during an activation

ENHANCED OPERATIONS

Review case definitions, investigation forms, plans, and procedures Request targeted increases in specimen submissions, in collaboration with the Laboratory


requested Assign pre-identified and trained liaison to serve in the SMOC Continue to: Coordinate influenza and other respiratory virus surveillance and investigations, as

described in the Texas Influenza Surveillance Handbook Monitor and maintain NEDSS Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to HSR and LHD staff on investigations of novel

influenza or other respiratory viruses with pandemic potential Maintain regular communication with CDC

INCREASED READINESS OPERATIONS Review specimen submission and testing criteria and adjust if needed, in conjunction with


data weekly, or as appropriate Enhance surveillance for influenza-like illness (ILI) for at least four (4) weeks or two (2)

incubation periods, whichever is longer, following identification of the last case of novel influenza or other respiratory virus



Provide pre-identified, trained liaison to serve in the SMOC Continue to:


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Coordinate influenza and other respiratory virus surveillance and investigations, as described in the Texas Influenza Surveillance Handbook

Monitor and maintain NEDSS Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to HSR and LHD staff on investigations of novel



requested

ESCALATED OPERATIONS Initiate surge testing activities, in collaboration with the Laboratory Services Section Continue to: Coordinate influenza and other respiratory virus surveillance and investigations, as

described in the Texas Influenza Surveillance Handbook Monitor and maintain NEDSS Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to HSR and LHD staff on investigations of novel










EMERGENCY RESPONSE OPERATIONS Revise case criteria and outbreak definitions, in conjunction with the EAG, if appropriate Conduct seasonal influenza surveillance and epidemiologic investigations of highest priority

influenza or other respiratory virus with pandemic potential reports Regularly review surveillance data and activities and consider scaling back operations Continue to: Coordinate influenza and other respiratory virus surveillance and investigations, as

described in the Texas Influenza Surveillance Handbook


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Monitor and maintain NEDSS Monitor all data sources for influenza or other respiratory virus activity Maintain and post influenza weekly report on website Provide consultations and guidance to HSR and LHD staff on investigations of novel









Monitor surge testing activities and adjust accordingly, in collaboration with the Laboratory Services Section



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LABORATORY SERVICES SECTION

ROUTINE OPERATIONS Conduct influenza and other respiratory virus surveillance testing, as described in the Texas

Influenza Surveillance Handbook Consult with Emerging and Acute Infectious Disease Branch (EAIDB) regarding testing of

non-routine specimens Identify and train liaison to serve in the State Medical Operations Center (SMOC) during an

activation

ENHANCED OPERATIONS Review seasonal influenza surveillance and laboratory protocols Complete verification of U.S. Centers for Disease Control and Prevention (CDC)-provided

novel respiratory virus or variant influenza virus protocols Assign pre-identified and trained liaison to serve in the SMOC Continue to: Conduct influenza and other respiratory virus surveillance testing, as described in the Texas

Influenza Surveillance Handbook Consult with EAIDB regarding testing of non-routine specimens

INCREASED READINESS OPERATIONS Review specimen submission and testing criteria and adjust if needed, in collaboration with

EAIDB and the Epidemiology Advisory Group (EAG) Conduct respiratory virus specimen testing based on established testing criteria, in

collaboration with EAIDB, referring to CDC when appropriate Maintain inventory control and order additional supplies, as needed Cross-train laboratory personnel, as needed Provide pre-identified, trained liaison to serve in the SMOC Continue to: Conduct influenza and other respiratory virus surveillance testing, as described in the Texas

Influenza Surveillance Handbook Consult with EAIDB regarding testing of non-routine specimens

ESCALATED OPERATIONS Initiate surge testing activities, in collaboration with EAIDB Augment existing laboratory staff and capacity, as needed, to support response activities

throughout the state, in coordination with the SMOC Continue to: Review specimen submission and testing criteria and adjust if needed, in collaboration with


collaboration with EAIDB, referring to CDC when appropriate Maintain inventory control and order additional supplies, as needed Cross-train laboratory personnel, as needed Provide pre-identified, trained liaison to serve in the SMOC


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EMERGENCY RESPONSE OPERATIONS Regularly review surveillance data, in collaboration with EAIDB, and consider scaling back

operations Continue to: Monitor surge testing activities and adjust accordingly, in collaboration with EAIDB and the

EAG Review specimen submission and testing criteria and adjust if needed, in collaboration with


collaboration with EAIDB, referring to CDC when appropriate Maintain inventory control and order additional supplies, as needed Cross-train laboratory personnel, as needed Provide pre-identified, trained liaison to serve in the SMOC Augment existing laboratory staff and capacity, as needed, to support response activities

throughout the state, in coordination with the SMOC


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IMMUNIZATION BRANCH

ROUTINE OPERATIONS Promote seasonal vaccination for everyone six months of age or older, based on current

recommendations Analyze seasonal vaccination rates Develop, produce, and distribute educational information, outreach, pamphlets, radio spots,

posters, etc. Survey the Health Service Regions (HSRs) and Texas Vaccine for Children (TVFC)

providers annually for projected vaccine needs for the upcoming season Submit estimated vaccine order for the upcoming season to U.S. Centers for Disease

Control and Prevention (CDC) Facilitate seasonal vaccination of health department staff and qualifying public sector clients Recruit new providers for TVFC and ImmTrac Collaborate with Emerging and Acute Infectious Disease (EAIDB) to monitor surveillance

findings Monitor vaccine safety with the Vaccine Adverse Event Reporting System (VAERS) and the

Texas Poison Control Network Identify and train liaison to serve in the State Medical Operations Center (SMOC) during an

activation

ENHANCED OPERATIONS Monitor and review vaccine development, if applicable Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Assign pre-identified and trained liaison to serve in the SMOC Continue to: Promote seasonal vaccination for everyone six months of age or older, based on current


posters, etc. Facilitate seasonal vaccination of health department staff and qualifying public sector clients Recruit new providers for TVFC and ImmTrac Collaborate with EAIDB to monitor surveillance findings Monitor vaccine safety with the VAERS and the Texas Poison Control Network

INCREASED READINESS OPERATIONS Communicate with CDC to determine a seasonal vaccine allocation and distribution pan,

which includes the identification and prioritization of priority high-risk populations based on surveillance data

Convene Vaccine Allocation Advisory Committee (VAAC) to determine high-risk populations for vaccine

Develop the seasonal vaccine allocation and distribution plan based on the identified high-risk and prioritized populations

Collaborate with medical providers that receive vaccine from DSHS to identify their high-risk populations and plan for potential seasonal vaccine distribution to these providers’ offices


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Develop a plan to identify and recruit non-traditional medical providers for vaccine distribution and administration

Provide pre-identified, trained liaison to serve in the SMOC Continue to: Monitor and review vaccine development, if applicable Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Promote seasonal vaccination for everyone six months of age or older, based on current



ESCALATED OPERATIONS Communicate regularly with CDC regarding new influenza strains or other respiratory virus




Communicate with CDC regarding high-risk populations and possible changes in recommendations

Determine and issue recommendations for local seasonal vaccination clinics, if indicated Monitor the percentage of the population that has received seasonal vaccine, if applicable Determine when eligibility criteria for DSHS-supplied seasonal vaccine should be

suspended Implement seasonal vaccine allocation and distribution plan based on priority high-risk

populations Prepare to activate the emergency module within ImmTrac to track antivirals, immunizations,

and medications administered to individuals during the emergency response effort Continue to: Provide pre-identified, trained liaison to serve in the SMOC Collaborate with medical providers that receive vaccine from DSHS to identify their high-risk

populations and plan for potential seasonal vaccine distribution to these providers’ offices Monitor and review vaccine development, if applicable Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Promote seasonal vaccination for everyone six months of age or older, based on current


posters, etc. Facilitate seasonal vaccination of health department staff and qualifying public sector clients Recruit new providers for TVFC and ImmTrac Collaborate with EAIDB to monitor surveillance findings


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Monitor vaccine safety with the VAERS and the Texas Poison Control Network

EMERGENCY RESPONSE OPERATIONS Suspend eligibility criteria for DSHS-supplied seasonal vaccine, if appropriate Provide DSHS-supplied seasonal vaccine to priority high-risk populations and then to the

general public, if appropriate Support mass vaccination clinics, if applicable Activate the emergency module within ImmTrac to track antivirals, immunizations, and

medications administered to individuals during the emergency response effort Regularly review surveillance data and consider scaling back operations Continue to: Provide pre-identified, trained liaison to serve in the SMOC Communicate regularly with CDC regarding new influenza strains or other respiratory virus




Communicate with CDC regarding high-risk populations regarding possible changes in recommendations

Monitor the percentage of the population that has received seasonal vaccine, if applicable Collaborate with medical providers that receive vaccine from DSHS to identify their high-risk

populations and plan for potential seasonal vaccine distribution to these providers’ offices Manage TVFC provider seasonal vaccine operations Recommend updates to the DSHS website Monitor seasonal vaccine availability at the local, regional, state, and national levels Promote seasonal vaccination for everyone six months of age or older, based on current




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PHARMACY BRANCH

ROUTINE OPERATIONS Procure, receive, store, and distribute seasonal influenza vaccine for Health Service

Regions (HSRs), local health departments (LHDs), and private providers in coordination with the Immunization Branch

Provide seasonal influenza vaccine and medical supplies for DSHS employee immunization clinics


Identify and train liaison to serve in the State Medical Operations Center (SMOC) during an activation

ENHANCED OPERATIONS

Assign pre-identified and trained liaison to serve in the SMOC Continue to: Procure, receive, store, and distribute seasonal influenza vaccine for HSRs, LHDs, and



and LHDs

INCREASED READINESS OPERATIONS Collaborate with other DSHS programs to maintain situational awareness of current



and capacities, and request additional resources, as needed Provide pre-identified, trained liaison to serve in the SMOC Continue to: Procure, receive, store, and distribute seasonal and novel influenza vaccine, if available, for



and LHDs

ESCALATED OPERATIONS Purchase, receive, process orders, and distribute pharmaceuticals and medical supplies, as

needed and as capacity allows Establish and operate a Strategic National Stockpile (SNS) drug repackaging site, if needed,

and if resources are available to support the effort Continue to: Provide pre-identified, trained liaison to serve in the SMOC Collaborate with other DSHS programs to maintain situational awareness of current

response activities


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Communicate with pharmacy associations and community or institutional pharmacies and provide subject matter expertise and guidance, as needed

Assess staffing, operations, pharmaceutical inventories, warehousing, and other capabilities and capacities, and request additional resources, as needed

Procure, receive, store, and distribute seasonal and novel influenza vaccine, if available, for HSRs, LHDs, and private providers, in coordination with the Immunization Branch



EMERGENCY RESPONSE OPERATIONS Regularly review surveillance data, in collaboration with EAIDB, and consider scaling back

operations Continue to: Provide pre-identified, trained liaison to serve in the SMOC Collaborate with other DSHS programs to maintain situational awareness of current



and capacities, and request additional resources, as needed Procure, receive, store, and distribute seasonal and novel influenza vaccine, if available, for



and LHDs Purchase, receive, process orders, and distribute pharmaceuticals and medical supplies, as

needed and as capacity allows Operate a SNS drug repackaging site, if needed, and if resources are available to support

the effort


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ZOONOSIS CONTROL BRANCH (ZCB)

ROUTINE OPERATIONS Regularly communicate with Texas Animal Health Commission (TAHC) and other animal

health partners Identify and train liaison to serve in the State Medical Operations Center (SMOC) during an

activation

ENHANCED OPERATIONS Share surveillance data, in collaboration with Emerging and Acute Infectious Disease

Branch (EAIDB) Assign pre-identified and trained liaison to serve in the SMOC Continue to: Regularly communicate with TAHC and other animal health partners

INCREASED READINESS OPERATIONS Provide pre-identified, trained liaison to serve in the SMOC Continue to: Share surveillance data, in collaboration with EAIDB Regularly communicate with TAHC and other animal health partners

ESCALATED OPERATIONS Continue to: Provide pre-identified, trained liaison to serve in the SMOC Share surveillance data, in collaboration with EAIDB Regularly communicate with TAHC and other animal health partners

EMERGENCY RESPONSE OPERATIONS Provide pre-identified, trained liaison to serve in the SMOC and/or Epidemiology Advisory

Group (EAG) Regularly review surveillance data and consider scaling back operations Continue to: Share surveillance data, in collaboration with EAIDB Regularly communicate with TAHC and other animal health partners


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EMERGENCY RESPONSE OPERATIONS EPIDEMIOLOGY ADVISORY GROUP (EAG) (Composed of DSHS laboratory, epidemiology, and medical expert representatives) Provide epidemiology and surveillance data to State Medical Operations Center (SMOC)

staff and DSHS leadership Provide fact sheets for the public for distribution through Center for Policy and External

Affairs (CPEA) Provide consultation to the State Medical Operations Center (SMOC) and DSHS leadership Refine the outbreak case definition, when indicated Analyze and interpret data on Texas cases Make recommendations on control measures, based on available data Regularly review surveillance data and consider scaling back operations

Respiratory Viruses Having Pandemic Potential · The plan focuses on the roles and responsibilities...

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